


*& 



^ 










.a/ 




^ J 



A TREATISE 



ON 



AND ITS CONSEQUENCES, 



CALLED 



NERVOUS AND BILIOUS COMPLAINTS; 



WITH 



OBSERVATIONS 



ON 



THE ORGANIC DISEASES, 



ITT WHICH THET SOMETIMES TERMINATE. 






BY A. P. W. PHILIP, M. D. F. R. S. Ed. &c. 



THIRD EDITION, 

WITH SOME ADDITIONAL OBSERVATIONS. 



PHILADELPHIA: 



H. C. CAREY AND I. LEA, CORNER OF CHESTNUT AND FOURTH STREET, 
AND J. CRISS)', NO. 177, CHESTNUT STREET. 

J. Crissy & G. Goodman, printers. 

1823. 



ftf 






"0 



TO THE 

PRESIDENT, 
FELLOWS AND LICENTIATES, 

OP THE 

ROYAL COLLEGE OF PHYSICIANS 

OF LONDON, 
THE FOLLOWING TREATISE 

IS RESPECTFULLY DEDICATED 
I 

»BY A MEMBER, 

WHO IS DEEPLY IMPRESSED WITH THE ADVANTAGES WHICH THE 

PROFESSION OF MEDICINE HAS DERIVED FROM 

THE INSTITUTIONS, AS WELL AS THE 

SCIENCE, OF THAT COLLEGE. 



5, Haztoveu Square,? 
November, 1321. S 



^\ err- 



Preface - - - - - 

Preface to the first edition 

A TREATISE, &c. ------ 

CHAPTER I. 

Op the symptoms of Indigestion. - 

Of the symptoms of the first stage of Indigestion 
Of the symptoms of the second stage of Indigestion * 
Some observations on the third stage of Indigestion 
Of the various forms and comparative duration of the 
different stages of Indigestion - 

CHAPTER II. 
Of the causes of Indigestion - 

Section i. 
Of the process of digestion 

Section ii. 
Of the remote causes of Indigestion - -^ 

Section hi. 
Of the immediate causes of Indigestion 

CHAPTER III. 

Of the treatment of Indigestion - 



Page. 

vii 
ix 

11 



14 

ib. 
25 
30 



37 



si. 



46 



53 



70 



VI CONTENTS. 



Section i. 



Page. 

Of the treatment of the first stage of Indigestion - 70 
Of the diet in Indigestion ----- 71 
Of exercise in Indigestion ----- 88 
Of the medicinal treatment in the first stage of Indiges- 
tion 96 

Of the preparative means - - - - ib. 
Of the treatment when the disease is confined to the 

stomach and bowels ----- 99 
Of the treatment when the disease has spread farther 

than the stomach and bowels - 109 

Section ii. 

Of the treatment of the second stage of Indigestion 116 
Of certain trains of symptoms, whose treatment does 

not fall under the general plan of cure - - 137 
Of the concurrence of the second stage of Indigestion 

and fever - - - - - ' - - 152 

Recapitulation - - - - - - 157 

CHAPTER IV. 

Of the third stage of Indigestion - - - 159 

Section i.' 

Of dyspeptic phthisis - - - - - 162 

Of the symptoms of dyspeptic phthisis - - ib. 

Of the causes of dyspeptic phthisis - - - 167 

Of the appearances on dissection in dyspeptic phthisis 168 

Of the nature of dyspeptic phthisis - 169 

Of the treatment of dyspeptic phthisis - - - 174 

Section ii. 

Of habitual asthma 183 

Of the employment of galvanism in habitual asthma ib. 



PREFACE 

TO THE 

FIRST EDITION 



My chief objects in the following Treatise have been to give 
arrangement to the various affections which have been termed 
nervous and bilious; to ascertain the nature of the disease on which 
they depend; to trace the causes which determine them to assume 
the various forms in which they are presented to us, and to deter- 
mine the appropriate treatment of each of these forms. 

In enumerating the symptoms, I have been led to enter more 
fully than, I believe, has hitherto been done, into the manner in 
which the sympathy of parts influences the phenomena and treat- 
ment of diseases, and thus to endeavour to ascertain some of the 
laws by which it is regulated. 

An attempt has been made to distinguish the symptoms which 
are the more immediate effects of the remote causes, from those 
which arise from the continuance of the disease itself, and to show. 
that on a correct knowledge and consequent discrimination of 
these two classes of symptoms, the successful treatment, in a great 
degree depends. 

My attention has been particularly directed to the latter, by 
which the changes which take place in the progress of the dis- 
ease are indicated. I have endeavoured to ascertain the nature 
of these changes, and the manner in which they influence the va- 
rious functions, .and at length, in many instances, destroy the or- 
ganization of some vital part. 



Vlll PREFACE. 

The adaptation of the means of cure to the changing nature of 
the disease, has been constantly kept in view; for similar trains 
of symptoms, at its different periods, we shall find, require different, 
and sometimes even opposite, means of cure. 

I have attempted to point out the influence of regimen, and to 
determine the rules by which the employment of mercury, which, 
we have reason to believe, has become too indiscriminate in this 
disease, should be regulated, and the limits at which its beneficial, 
no longer counterbalance its injurious, effects. 

In the composition of the following Treatise, recourse has not 
been had to the works of others. It can not, therefore, be regard- 
ed as an attempt to present to the reader the sum of our know T - 
ledge on the subject. I offer it simply as the result of my obser- 
vations, and the reflections suggested by them, during a space of 
twenty-five vears. 



PREFACE 



TO THE 



SECOND EDITION. 



In revising the following Treatise, the author's only object has 
been to render it more useful to the practitioner. 

As hardly half a year has elapsed since its publication, any con- 
siderable enlargement of it is not to be expected; but he hopes 
that the present edition will be found in several respects improved. 
Many observations have been added, and an attempt has been 
made, in several passages, to explain more fully the principles 
which led to the treatment recommended in it, the author's con- 
fidence in which, he is happy to say, has been strengthened since 
the appearance of the first edition, by communications from seve- 
ral physicians, to some of whom he has not the honour of being 
personally known. 

For the sake of hasty readers, who seldom see arrangement in 
a work where the subject is at all complicated, without numerous 
divisions and references, the author has introduced a greater num- 
ber of these, which, to the diligent who bear in mind the plan 
laid down and feel no difficulty in perceiving how the different 
parts of the subject arrange themselves under it, are often super- 
fluous, and therefore unwelcome interruptions. 

% 



A TREATISE 



INDIGESTION, &o. 



It is a remarkable fact, that there is hardly any disease less 
understood than that which is most frequently presented to us, 
and known under the vague denominations of bilious, nervous, 
and stomach complaints; which seems the more extraordinary, 
because there is none of greater importance, whether we regard 
its variety, its consequences, or its connexion with other diseases. 

This arises, I believe, from two circumstances. The first re- 
lates to the nature of the disease itself. In its early stages, in 
which other fatal diseases sometimes give us an opportunity of 
examining the organs chiefly affected, the cause of derangement 
is in parts too minute for observation; and before its fatal termi- 
nation, it is so changed, that the inspection of those who fall a 
sacrifice to it, throws little light on its origin. Who, for example^ 
can learn from the appearances in the body of a drunkard, what 
particular state of the parts concerned caused the dyspeptic symp- 
toms, which preceded the indurated liver, and distended abdo- 
men? The second circumstance to which I allude, relates to the 
causes of the disease. We know that the digestive power of the 
stomach, depends on a fluid secreted in it, and consequently, 
that a deranged state of this fluid must be the cause of the symp- 
toms of Indigestion; but we can make little practical use of this 
knowledge, unless we know the immediate causes of its derange- 



12 ON INDIGESTION 

ment, and the particular manner in which the derangement 
operates in producing the symptoms of the disease. These are 
the questions which chiefly interest ihe physician; and yet, as far 
as I know, no attempt has been made to answer them; and the 
practice in this disease remains uncertain and ill defined. 

My attention has frequently been arrested by finding, that 
cases, in which the usual means, in many instances successful, 
had failed, and indeed often aggravated the symptoms, yielded 
readily to an opposite plan. Cases relieved by opposite plans of 
treatment, it is evident, can not be of the same nature, however 
similar their causes and symptoms. They are either different 
diseases, or different stages of a disease, whose nature undergoes 
some change in its progress. 

I have arranged the various cases, of which I am about to treat, 
under the denomination of Indigestion, because the symptoms of 
this derangement form a more or less prominent feature in all, 
and all begin with these symptoms I prefer this term to dyspep- 
sia, which has been employed by medical writers to express a dis- 
ease much less varied, and of much less extent than that I am 
about to treat of. Indigestion, therefore, in the sense in which I 
shall use this term, is not synonymous with dyspepsia, but in- 
cludes it. 

The following Treatise may be divided into four parts: — In 
the first, 1 shall present to the reader, a review of the symptoms 
of Indigestion, and its more immediate consequences; in the se- 
cond, consider the remote causes of this disease, the manner in 
which they excite it, and the nature of the changes which take 
place in its progress; in the third, detail the plans of treatment 
which have appeared to me most successful in it; and in the last, 
make some observations on the symptoms and treatment of the 
organic derangements, in which it often terminates. 

By a disease we mean, not only that collection of symptoms 
which are present at any onetime, but also those which appear 
in succession, arising from the same source. We shall find In- 
digestion the most varied of all diseases. Beginning from simple 
and apparently unimportant deviations from health, it gradually 



AND ITS CONSEQUENCES. 13 

becomes so complicated, and often, at length, so undermines every 
power of the system, that it is difficult to give a view of its symp- 
toms, which shall be at once sufficiently full and distinct. It is an 
affection of the central part of a most complicated structure, ca- 
pable of influencing even its remotest parts, and each, through 
many channels, and in various ways. 



1 4 OF THE SYMPTOMS 



CHAPTER L 
OF THE SYMPTOMS OF INDIGESTION. 



I shall divide the symptoms of indigestion into three stages. 
While this division renders the account of them more distinct, it 
at the same time answers a more important purpose, for we shall 
find the disease in these stages varying in its nature, as well as in 
its symptoms. 

Of the Symptoms of the First Stage. 

The first symptoms of Indigestion are either such as immedi- 
ately arise from the undigested food itself; or from the state of the 
stomach and bowels, which causes the disease, and the irritation 
of their nerves, occasioned by the undigested food, or their owr 
vitiated secretions. 

The symptoms which immediately arise from the undigested 
food are flatulence, distention of the stomach and bowels, and 
acid, oily and putrescent eructations. 

From the debility of the stomach and bowels, and irritation of 
the nerves, a greater variety of symptoms spring. Organs of such 
importance in the animal economy can not long be so deranged 
as to produce vitiated secretions, without at the same time, giving 
rise to other disturbance in the system. The debility of stomach, 
which prevents a due secretion of healthy gastric fluid, must at 
length, produce some of those other effects which we witness, 
when the powers of the stomach are disordered by any^offendins 
cause. 



OP INDIGESTION. 15 

An emetic, while it remains on the stomach, destroys the ap- 
petite, occasions nausea, sometimes pain, and produces, in conse- 
quence of the sympathy which exists between the stomach and 
every other part of the system, a general state of debility, now 
and then almost approaching to syncope. The surface is pale, 
cold, and shrunk, and the action of the heart is impaired, the pulse 
becoming small and feeble. The limbs perhaps tremble, and are 
always unequal to their usual exertions, and the mind is anxious 
and subdued. These symptoms, however, disappear as soon as 
the act of vomiting relieves the stomach from the offending cause. 

When we consider that the causes which disorder the powers 
of the stomach in Indigestion are of a more permanent nature, and 
that the contents which irritate its surface, although often remov- 
ed, as in the case of the emetic, are soon reproduced, we shall 
find little difficulty in perceiving the general rationale of the symp- 
toms of this disease. But, in order more particularly to ascertain 
the state of the stomach and bowels in its various stages, it will be 
necessary to take a closer view of its symptoms, and attempt a 
more minute investigation of their immediate causes. 

The symptoms which arise immediately from undigested food, 
exist in various degrees in different cases. In the very commence- 
ment of the disease, they are often the only symptoms which oc- 
casion much uneasiness, from which it appears, that the functions 
of the stomach may, for a certain time, be so disordered as to pro* 
duce a feeble, or otherwise vitiated secretion, without in any other 
waj very sensibly affecting the functions of the system. People 
frequently complain of a sense of distention after eating, and 
flatulent and acid eructations, who notwithstanding, enjoy good 
general health; and find that even these symptoms may be pre- 
vented by taking less food, and that of a more digestible quality; 
and, if they are prudent in this respect, and the constitution is 
otherwise sound, and not exposed to the effects of indolence, and 
other causes weakening the nervous system, the stomach will often 
recover its powers without further means. 

In the majority of cases, however, either from neglect on the 
part of the patient, or a greater degree of obstinacy in the cause, 



16 OF THE SYMPTOMS 

the above symptoms continue to recur. This never happens for 
any great length of time, without the other parts of the alimentary 
canal partaking of the disease. Their secretions also begin to 
suffer some deviation from the healthy state. Those of the intes- 
tines, for the most part, are impaired in quantity, and, at the 
same time, probably altered in quality. The bowels do not act so 
readily as usual, and they are occasionally distended and tense, 
especially some time after eating. The mouth is clammy, and 
the tongue more or less furred, particularly in the morning. 

But these symptoms, the patient finds, yield to some mild ape- 
rient, which, at the same time, promotes the action of the stomach, 
and his feelings on the whole, differ but little from those of health. 
He is more apt to be thirsty, his appetite is generally more or less 
impaired and variable, he complains of his feet being cold, but 
still his strength, and general appearance, are but little affected, 
and he seldom thinks it necessary to pay particular attention to 
symptoms which appear so slight and for the time yield so readily. 

By degrees, however, they recur more frequently, and begin to 
be attended with some depression of strength which at first is only 
occasional. This, in general, is the first thing which seriously 
calls his attention to the disease. The mind, if the disease pro- 
ceed, partakes of these returns of languor, and the patient at 
length finds it difficult at all times to command his attention, and 
upon the whole, that he is not capable of his usual mental efforts. 
His sleep is disturbed by perplexing dreams, and sometimes by 
fits of nightmare. In a large proportion of cases, however, he 
enjoys good nights, and even those who are troubled with dream- 
ing and restlessness, often feel more drowsy than usual. 

He now becomes alarmed, and occasionally feels a degree of 
despondency. Instead of thinking too lightly of his complaint, 
he often regards it in the most serious point of view, and can not 
be persuaded that any thing less than some important derange- 
ment, can produce the anxiety and depression by which his atten- 
tion gradually becomes wholly engrossed; for none but an atten- 
tive physician can know how slight a derangement of the alimen- 



ON INDIGESTION. 



17 



tary canal, especially after the habit of disease is formed, is capa- 
ble of essentially influencing every function of the system. 

While the symptoms thus proceed, a change, sooner or later, 
takes place, which marks an important step in the progress of the 
malady. The alvine discharge begins to deviate from the healthy 
appearance: it sometimes contains uncombined bile, sometimes it 
chiefly consists of bile; its colour at other times is too light, more 
frequently too dark; and occasionally, at length, almost black; at 
different times it assumes various hues, sometimes inclining to 
green, sometimes to blue, and sometimes it is mixed with, and 
now and then almost wholly consists of, undigested bits of food. 
When there is much straining, it often contains mucus in distinct 
masses, and not unfrequently, substances resembling bits of mem- 
brane. It frequently separates from the canal with more difficulty 
than usual, and leaves a feeling of the bowels not having been 
completely emptied 

We have reason to believe that the above change and variety 
of colour arise chiefly from the state of the bile, to which the al- 
vine discharge owes its natural tinge, being quite white, when no 
bile flows into the bowels. It would appear that the properties 
of the bile are sometimes changed without change of colour; but 
this is comparatively so rare, that if the colour of the alvine 
discharge be natural, we may generally im% that the function of 
the liver is duly performed. 

The disease has hitherto been what is called stomach com- 
plaints. It is now, from the various appearances of the vitiated 
bile, and the various symptoms which arise from the irritation it 
occasions in the alimentary canal, what is called bilious and ner- 
vous complaints. The former of the two last appellations has 
also arisen from the bile, of which there is sometimes a super- 
abundant secretion, being, occasionally, in consequence of the 
inverted action of the duodenum, thrown into the stomach; and 
there exciting nausea, headache, and bilious vomiting. 

Many conceive that the changes of colour in the alvine dis- 
charge are often to be ascribed more to circumstances in diet, 
and changes which the contents of the bowels undergo in their 

3 



18 OF THE SYMPTOMS 

passage through this canal, than to the state of the bile; and, I 
have no doubt, these causes operate to a greater or less extent. 
The long delay of their contents in the bowels generally darkens 
the colour; a railk diet produces a discharge of a lighter colour 
than one consisting chiefly of animal food, and some vegetables 
and medicines communicate a certain tinge to the discharge. 
According to my experience, however, these causes, on the whole, 
produce less effect than might be < xp^cted, and, with a little at- 
tention on the part of the practitioner, will seldom mislead him. 
It must always be kept in view, that the appearance of the dis- 
charge often changes, when it has remained for some time out of 
the body. 

The urine also deviates from the healthy state. In its most 
healthy state, it is perfectly transparent when passed, and remains 
so nfter it cools, its colour being more or less deep in proportion 
to the degree in which its contents are diluted. It is, however, 
liable to some deviations from this state under circumstances 
which can hardly be said to affect the general health. 

It appears from some experiments which I made many years 
ago for the purpose of ascertaining the effects of various circum- 
stances in diet, &c, on the state of the urine, an account of which 
the College of Physicians of London did me the honour to pub- 
lish in the last volume of their Transactions, that when acid 
greatly prevails in the stomach and bowels, or the skin becomes 
more inactive than usual, so that it does not freely throw off the 
acid, which it appears from these experiments always passes by 
this organ, a red deposition, which consists of lithic acid, takes 
place from the urine after it has stood for some time, this fluid 
still remaining clear; and on the other hand, that, when the skin 
has been unusually excited, or an alkalescent state of the stomach 
and bowels prevails, it becomes turbid, and deposites a white se- 
diment, which has been ascertained, by the experiments of Dr. 
Wollaston, to consist of the phosphates of the urine. 

Both these states, particularly the former, are more apt to ap- 
pear in Indigestion than in ordinary health; and the urine in this 
disease is sometimes covered with a very thin oily film, which 



OP INDIGESTION. 19 

appears to arise from an imperfect state of the assimilating pro- 
cess Sometimes also it is limpid, and passed in unusually large 
quantities, more frequently scanty and too high coloured. It is 
then most apt, as we should a priori expect, to deposite the above 
sediments unless some degree of fever prevail, when it often 
either deposites nothing, or a little of the red sediment. 

A remarkable sympathy between the state of the kidneys and 
intestines is often observed in Indigestion, the urine remaining 
scanty and high coloured, when the bowels are constipated; 
and flowing freely, and of a paler colour, as soon as a free dis- 
charge from them has been obtained. Even in those dropsical 
affections which supervene on this disease, it is common for all 
diuretics to fail when the bowels are constipated, and for the 
operation of cathartics alone to be followed by a free discharge 
from the kidneys. 

The copious flow of urine which sometimes attend Indigestion 
seems frequently to arise from a failure in the action of the skin, 
as appears from some of the experiments just referred to. The 
kidneys and skin separate the same fluid from the blood, and a 
failure of secretion from the latter is often compensated by an in- 
crease of that from the former, if they have not by sympathy 
partaken too much of the state of the skin. Thus in dyspeptics 
an unusual application of cold to the surface, when the powers of 
the system are not able so to re-act as to support the due action 
of the skin under it, frequently occasions an increased flow of 
urine. 

The same cause often occasions a greater discharge from the 
bowels. It particularly demands attention in this disease, that, 
although the increased discharge from the bowels in the instance 
before us is of a watery nature, when the skin has, from the state 
of that disease, become uniformly languid, the increase is often in 
the solid, as well as liquid, contents of the bowels. On the same 
principle, the quantity which passes from the bowels of delicate 
children when the skin has become dry and shrivelled, is often 
astonishing, and that even when little nourishment is received, 
as if not only what ought to have passed by the skin, but a great 



20 OF THE SYMPTOMS 

deal of what lias been inhaled by this organ were deposited in a 
solid form in the alimentary canal. Some facts would lead us to 
suppose that in such a state of the skin, the inhalation by it is 
often very great. I have seen several gallons of water drawn off 
from a child ten or twelve years old, labouring under extensive 
abdominal disease, and apparently re-collected in eight or ten days, 
although but littlt fluid had been taken. 

What is here said is well illustrated by an opposite state of the 
system. In very great eaters, the alvine discharge is often no 
greater than in other people, but the secretion by the skin is found 
much more free. Even in a remarkable case of this kind, an 
account of which appeared in the journals of the day (1797) in 
which an individual could eat daily twelve or fifteen pounds of 
raw meat, and would have starved if confined to the allowance 
of two or three ordinary men, the alvine discharge was little, if 
at all, greater than usual, yet he continued thin, and the super- 
fluous quantity of food ran off by profuse night sweats. 

The sensible change in the appearance of the alvine secretions 
in Indigestion, is generally attended with some change in the 
other symptoms. The stomach is more apt to be oppressed after 
eating, the patient often observing that he feels as if there were 
not room for what he had taken. The bowels are frequently va- 
riable, diarrhoea often supervening without any evident cause, 
almost uniformly followed by fits of constipation. These, the pa- 
tient finds, can not now be removed by the simple medicines 
which at first restored due action to the bowels, larger doses or 
more active medicines are necessary, and their effect corresponds 
with the previous state of the bowels. The discharge is generally 
unsatisfactory, something seeming to be retained. It is very often 
watery, or frequent small semi-fluid, teasing, mixed with mucus, 
and sometimes streaked with blood, and after it has been repeated, 
often chiefly consists of mucus and a little blood, the passage of 
which is attended with much griping and bearing down, and fol- 
lowed by a constant desire o» further evacuation. The patient 
takes more medicine, with the hopes of a freer effect, but he thus 
often increases the straining more than the discharge. 



OP INDIGESTION. 21 

After this state of irritation has continued to recur for a great 
length of time, a degree of permanent spasmodic stricture some- 
times appears to take place in the rectum. This I have known 
happen to such a degree as to give a tape-like appearance to the 
alvine discharge for many months without intermission, and sug- 
gest the idea of organic stricture, till an examination of the part 
proved its real nature. A more temporary contraction of the rec- 
tum, occasionally giving this appearance to the discharge, is not 
an uncommon symptom. 

In the meantime the patient is harassed with a variety of other 
symptoms, arising from the irritation occasioned by the morbid 
contents of the alimentary canal, increasing languor, pains of the 
stomach, more frequently of the bowels, and particularly of the 
lower part of the bowels, sometimes continued, generally of the 
griping kind, a sense of heat, or, as the patient often calls it, 
burning, referred to the stomach, and now and then extending to 
the bowels, which sometimes proves the most obstinate and dis- 
tressing symptom of the disease, or of weight in the right hypo- 
chondriuni or lower part of the abdomen, with unusual disten- 
tion of the former, sometimes disappearing in a day or two, par- 
ticularly after freer evacuations, and returning again, at other 
times more stationary, a more foul and clammy tongue, nausea, 
more rarely vomiting, a depression of strength, which sometimes, 
particularly after the unsatisfactory operation of cathartics, al- 
most amounts to syncope, and a despondency that is hardly equal- 
led in any other disease. 

As these symptoms proceed, others, the consequence of the sym- 
pathy which exists between the stomach and other parts of the 
system, gradually show themselves. These are different in dif- 
ferent parts, and other complaints, of the head, affections of the 
sight, the hearing, smell, or taste. More or less habitual in- 
flammation, and even ulceration of the throat are by no means 
uncommon, and the voice and articulation are sometimes various- 
ly affected. The patient is distressed with spasms of the trunk 
or limbs, numbness, and even temporary loss of power in the lat- 



22 OF THE SYMPTOMS 

ter; and feelings of endless variety are described as sometimes 
in one part of the body and sometimes in another. 

By constant recurrence of such attacks without being uniformly 
ill, for the rapidity with which the patient rallies is often as great 
as that with which he is subdued, he is gradually rendered unfit 
for the active duties of life. This preys on his mind, increasing 
the despondency which makes a part of his disease, and which in 
its turn, by further debilitating the digestive organs, aggravates all 
the symptoms. 

These organs being no longer in a proper state to supply due 
nourishment, the body becomes emaciated, and more permanently 
feeble, the strength by degrees rallying less readily and less per- 
fectly after the frequent returns, and what was at first only a tem- 
porary depression from a debilitating cause affecting the nerves 
of the alimentary canal, is gradually changed into real debility, 
the countenance, which is almost alwavs a sure index of what is 
passing internally, becoming pale and haggard. 

It is of great importance in judging of the state of this disease 
to distinguish between debility and what may be called depres- 
sion of strength. In the latter the action of the vital powers is 
only impeded, in the former their vigour is impaired. The one 
may supervene in a moment, and may be as instantly relieved; 
the other, unless the cause be very powerful, comes on more slow- 
ly, and in all cases slowly removed. We have an instance of depres- 
sion of strength in the effects of an offending cause in the stomach 
and bowels, which cease as soon as the cause ceases to operate; of 
debility in the effects of repeated irritation of these organs, which 
continue after the cause of irritation no longer exists. Thus the de- 
bility, which appears suddenly at the commencement as well as at 
otherperiods of Indigestion, is oftrifling importance, compared with 
that more permanent debility which supervenes gradually, the symp- 
toms of which are often slight compared with those of temporary 
depression of strength, but which is always more difficult of cure. 
The one is chiefly important as it indicates what is passing inter- 
nally; the other proves that the powers of the constitution are 



OF INDIGESTION. 26 

yielding to the disease. Either mistaken for the other leads to 
serious errors in practice. 

The patient, often from an early period of Indigestion, feels 
some uneasiness on lying on the left side, more rarely this is the 
case with respect to the right side. In the progress of the dis- 
ease, lying on either side becomes uncomfortable, and, in its ad- 
vanced stages, the only easy position is on the back, with the 
shoulders a little raised, and generally inclined to the right side. 

Such is the general course of the disease we are considering. 
Those who are acquainted with the laws of sympathy, which in so 
striking a manner modify the phenomena of disease, will expect, 
that in the parts which most sympathize with the stomach and 
bowels, and consequently partake most of their affections, the 
symptoms of this disease will be found most varied. Thus it is 
that the tongue and other parts of the mouth are variously affect- 
ed from the commencement. Their secretions become more and 
more thick and clammy, the former being covered with a white or 
brownish mucus, which also more or less adheres to, and irri- 
tates the fauces; sometimes all these parts are more or less parch- 
ed and stiff, at other times the saliva is morbidly thin and copious, 
the tongue being cleaner but often of a whitish and sodden appear- 
ance. In protracted cases when the symptoms have been rather 
obstinate than severe, and considerable debility has come on, this 
symptom is often very troublesome, the saliva frequently running 
from the mouth. 

In the advanced stage of the more severe cases, there is often 
a viscid frothy secretion from the fauces, while the mouth in gen- 
eral is drier than usual, which forms a very prominent feature of 
the disease. The patient is constantly hawking up this matter } 
particularly after eating, and will tell you that all his food turns 
to phlegm. This discharge is sometimes so great and harassing 
as to prove the most distressing symptom, and seems not a little 
to add to the debility. In some cases the tongue, in the more 
advanced stages, becomes clean, shining, and morbidly smooth 5 
and at length affected with aphtha?. This state of it is seldom 



24 OP THE SYMPTOMS 

observed except when a considerable degree of fever has super* 
vened, which is not uncommon at these periods. 

The skin, in protracted cases, often becomes dry, shrivelled, and 
sometimes, at length, almost scaly, and the hair is parched and 
inclined to stand on end, the whole surface is cold, the patient is 
constantly hanging over the fire, and even experiences frequent 
fits of chilliness approaching to shivering; he bears all extremes 
of temperature ill, being as much oppressed by a very high tem- 
perature as he is chilled by a low one; wounds heal less readily 
than usual, and the skin is not untrequently affected with a trouble- 
some itching, which often shifts its seat, or with nettle rash, 
herpes, and other species of eruptions, and even ulceration some- 
times supervenes without any evident cause. 

Besides the more transitory symptoms in the head, which have 
been mentioned, there are often marks of an habitual undue de- 
termination of blood to the brain, producing languid inflammation 
of the eyelids, tinnitus aurium, and occasionally throbbing of the 
temples. Some are oppressed with drowsiness, sometimes almost 
approaching to stupor, others with almost constant pain more or 
less severe, sometimes in the back of the head, more frequently in 
the forepart, others are subject to giddiness, and some even to sud- 
den fits of insensibility. 

The thoracic viscera are often particularly affected, occasional, 
and not unfrequently, more or less permanent, dyspnoea super- 
venes, and the patient is sometimes harassed by a dry and irrita- 
ting cough, or with fits of palpitation. 

When expectoration attends the cough, it is generally difficult, 
but brings considerable temporary relief. It deserves notice, that 
in this stage of the disease, he more frequently complains of pain 
in the left than in the right side; but the seat of the pain is very 
various, not unfrequently, it is chiefly in the back, about the 
shoulders, sometimes attended with itching, and in the limbs, 
more frequently in the legs than the arms. Irregularity of pulse 
and syncope are not unusual symptoms. The former I have re- 
peatedly known continue for years, even attended with the more 
characteristic symptoms of angina pectoris without organic affec- 



OP INDIGESTION. AQ 

lion of the heart having supervened, although under such circum- 
stances it is always to be dreaded. It is not uncommon for the 
muscles of the chest to become painful on motion, and even to the 
touch. The abdominal muscles also are sometimes affected in 
the same way. This affection is apt to be worse at night, so that 
the patient turns himself in bed with difficulty and pain. 

Of the Symptoms of the Second Stage of Indigestion. 



At various periods of the disease, for the most part after repeat- 
ed derangement of the hepatic function, comes on a permanent 
tenderness on pressure, sometimes but slight, of the soft parts close 
to the edge of the cartilages of the false ribs on the right side, 
after they have turned upwards to be joined to the sternum. This 
spot is often very circumscribed, and always lies about halfway 
between the end of the sternum and the place at which the lowest 
of the cartilages begins to ascend; and the cartilage itself near the 
tender part often becomes very tender, not unfrequently indeed 
much more so than the soft parts. The patient in general is not 
aware of this tenderness till it is pointed out by the physician. 

This symptom never exists long and to any considerable degree 
without the pulse becoming hard, and it often at the same time 
becomes rather more frequent than in health. 

There is no other symptom of the disease before us to which I 
am so anxious to call the reader's attention as to what I have 
termed a hard pulse, because on it much of the proper treatment 
seems to depend. It sometimes happens, especially when the 
tenderness in the epigastrium is considerable, that the pulse be- 
comes such as would on all occasions obtain the name of hardj 
but more frequently the hardness is only to be distinctly perceiv- 
ed by examining the pulse in a particular way. 

Those who have been much in the habit of examining the dif- 
ferent states of the pulse must be aware, that its hardness is most 
perceptible when a slight degree of pressure is employed. A cer- 

4 



«t> OP THE SYMPTOMS 

tain degree, by greatly compressing the vessel, will give some 
feeling of softness to the hardest pulse, and a slight degree of hard- 
ness is not perceptible with the pressure generally employed in 
feeling the pulse. If the pressure be gradually lessened till it 
comes to nothing, it often happens that a distinct hardness of 
pulse is felt before the pulse wholly vanishes under the finger, 
when no hardness can be distinguished in the usual way of feel- 
ing it. 

This is in no degree the case in a healthy pulse, nor even in 
the first stage of the disease we are considering. But when the 
tenderness of the epigastrium is at all a prominent feature, it may 
always be perceived, that is, there is then a certain degree of 
pressure, sometimes very slight, under which the pulse gives a 
decidedly wiry sensation to the finger, the degree of pressure, un- 
der which the hardness may be perceived, denoting its degree. 
It is most sensible immediately after the patient has been using 
exercise. 

I consider the occurrence of the tenderness of the epigastrium 
and hard pulse as denoting the second stage of the disease, be- 
cause from the time of their appearance, at whatever period this 
happens, we shall find its nature, and consequently the plan of 
treatment suited to it, changed. 

These symptoms are generally accompanied with others, indi- 
cating some degree of feverishness. The chilliness of which the 
patient has long complained is now sometimes, and independent- 
ly of any change of temperature in the surrounding medium, in- 
terrupted by languid and oppressive fits of heat; and the hands 
and feet, instead of being uniformly cold, as in the earlier stages, 
often burn, particularly during the first part of the night, while at 
other times they are more obstinately cold. The thirst also often 
increases, and sometimes there is a tendency to partial sweats in 
the morning, especially if the patient lie longer than usual; and 
these symptoms are generally attended with an increase in some 
of those of the first stage. 

When the tenderness of the epigastrium and hard pulse are 
considerable, there is generally, more or less an inability of ex- 



OP INDIGESTION. 27 

ercise, except of the passive kind, much active exercise producing 
an insupportable languor; but slight degrees of the above symp- 
toms are generally unattended by this inability. 

The tenderness of the epigastrium, after it has lasted for some 
time, generally begins to be attended with some degree of fulness 
in the part, and to extend downwards along the edge of the car- 
tilages, till at length there is a degree of fulness, and sometimes 
tenderness, throughout the right hypochondrium; which feels firm- 
er than the left; but the tenderness is seldom so great as in the 
part of the epigastrium above described. Sometimes the pressure, 
both there and in the hypochondrium, rather produces a sense of 
oppression affecting the breathing than pain. Sometimes, parti- 
cularly in the epigastrium, it occasions pain passing through the 
body towards the back, sometimes quite to the back, at other 
times a fixed pain or sense of oppression under the sternum, and % 
in some cases, a pain extending to the left side. 

There is often, we have seen, a degree of fulness in the right 
hypochondrium at earlier periods; but it is then more transitory, 
being generally relieved, and sometimes removed by the effects 
of cathartics, and not unfrequently, spontaneously disappearing 
and returning again. 

Such is the regular course of what I have called the first and 
second stages of Indigestion; but there is a class of symptoms, or 
rather, a modification of certain symptoms, which, although not 
forming an essential, constitutes, when it does appear, the most 
important part of the disease. We have seen that even from the 
commencement, distant parts of the system, particularly those 
which sympathize most with the stomach, suffer. When any part 
has suffered more frequently than the rest, its powers are gradual- 
ly weakened, and as the second stage proceeds its affections as- 
sume in some degree a different and more prominent character. 
Thus headach, affections of the chest, of the lower bowels, &c, 
often at length become the chief disease. 

It particularly deserves attention that the secondary affections 
undergo the same change with the disease from which they spring. 
In the first stage they are merely nervous affections, disappearing 



2S OF THE SYMPTOMS 

as soon as the cause which produced them ceases to operate. In the 
second stage they assume an inflammatory character, become more 
and more of a permanent nature, and in the same proportion, more 
independent of the original disease, till at length they can not be 
removed without an appropriate mode of treatment directed to the 
part secondarily affected. This circumstance renders a particu- 
lar consideration of them necessary in laying down the means of 
cure: it will therefore tax the reader's memory less and save re- 
petition to defer any further account of them till we come to this 
part of the subject. I shall then also, for the same reasons, lay 
before him such observations relating to the nature of these affec- 
tions as exclusively apply to them. After this explanation I hope 
I shall not be accused of a neglect of order in what I shall say 
on this part of the subject. 

m In reviewing the symptoms of the disease which forms the sub- 
ject of this Treatise, it particularly deserves attention that all the 
diseases which are called, and strictly speaking are, nervous, are 
apt to run into febrile diseases; injury ensuing if at the pe- 
riod when this change takes place, a corresponding change is not 
made in the means of cure. Many facts point out, that long con- 
tinued nervous irritation at length terminates in inflammation of 
the organ affected. Even an affection, which in the first instance, 
is wholly sympathetic, arising from irritation applied to a distant 
part, will, if severe or long continued, terminate in inflammation 
of the organ sympathetically affected. 

In the 43d, 44th and 45th Sections of MorgagnVs 21st Epistle, 
the reader will find the pleuritis verminosa treated of at some 
length; he mentions one case in which all the symptoms of pleu- 
risy were well marked that terminated favourably by bloody vo- 
miting which brought up a worm. We might in this instance 
attribute the relief obtained rather to the loss of blood than the 
worm; but he refers to a paper of Pedratto on the pleuritis ver- 
minosa, where the relief obtained by the expulsion of worms from 
the stomach and intestines, particularly from the former, is un- 
equivocally proved. 

Jt there appears that all who vomited the worms, or passed 



OF INDIGESTION. 29 

them by the bowels, recovered, while those who did not, died. 
All the common means of treatment in inflammation of the lungs 
failed; medicines which destroyed the worms alone were suc- 
cessful. While their expulsion immediately removed the disease, 
it is impossible for us to believe that real imflammation of the 
lungs had existed; yet in those in whom the disease had been al- 
lowed to take its course, the same appearances were found in the 
thoracic viscera as in those who die of other forms of pneumonia. 

We often see the same principle strikingly illustrated in the 
diseases of children. We find it obtaining indeed in every in- 
stance. When affections of the liver produce pain in the shoul- 
der, there is no disease in this part. The pain is merely sympa- 
thetic. If we press or rub the shoulder, the patient feels no 
more uneasiness from it than he would in the other shoulder; but 
after the pain has continued for a considerable time the shoulder 
itself often becomes affected, he can not then bear to have it 
pressed, and sometimes can not lie upon it. 

When inflammation spreads from the intercostal muscles to the 
lungs, it does not traverse the pleura, reaching the lungs by the 
fold by which this membrane is reflected over them. It passes 
at once from the pleura of the ribs to that of the lungs, between 
which there is no direct communication, for this often happens 
previously to any adhesion having taken place. Why is inflam- 
mation of the bowels as apt to spread to the contiguous parts with 
which they have no other immediate connexion, as to those which 
are in continuation with the diseased part? W r hy does loss of 
blood by the application of leeches to the skin over an inflamed 
organ often give more relief than loss of many times as much blood 
from a distant part? It is needless to multiply instances, whoever 
observes with attention the phenomena of disease will find them 
numberless. I have just had occasion to mention a striking one 
in which the tenderness on pressure of the internal parts of the 
epigastrium is communicated to the neighbouring cartilage. 

These facts teach an important lesson in the prevention of dis- 
ease, that the first beginnings of many sympathetic affections, 
however trivial, should be watched with care. The headache fre- 



■ 



30 OF THE SYMPTOMS 

quently occurring from disordered stomach, may at length become 
a disease of the head, itself; and there is no organ, we have rea- 
son to believe, in which disease may not arise in the same way. 
They teach a lesson of equal importance in the treatment of dis- 
eases, the necessity of being minutely acquainted with the history 
of the case, in order to ascertain, whether sympathy with other 
parts had contributed to produce disease in those now most pro- 
minently affected; for if this has been the case, and the affection 
of the former still continues, we shall attempt in vain to restore 
health by means directed only to the latter. 

It will appear, I think, from what I am about to say, that it is 
of the last importance in the treatment of Indigestion, to observe 
the period at which the above-mentioned change in its nature 
takes place, at which the disease ceases to be a case of mere 
nervous irritation, producing a disordered secretion; and begins to 
affect the sanguiferous, as well as the nervous system; which in 
many cases happens long before organic disease has taken place, 
but which, if not counteracted, is generally its precursor. 

Indigestion thus comes to be divided into three stages: the first, 
characterized by the various symptoms above enumerated, arising 
from the undigested food, from the state of the stomach and bow- 
els, which is the cause of the disease, and from its necessary con- 
sequence, the additional irritation to which these cavities are sub- 
jected by the undigested food and vitiated secretions; the second, 
characterized by tenderness, or other uneasiness on pressure in 
the part of the epigastric region above pointed out, and a degree 
ofharaness in the pulse, often accompanied by other febrile 
symptoms; and the third, by the symptoms of organic disease in 
the abdomen, chest, or head. 

Of the third stage of Indigestion. 

It appears from what has been said, that in the local affections 
of the second stage of Indigestion, the sanguiferous as well as ner- 
vous power of the part affected is involved in the disease. This 



OF INDIGESTION. 31 

state of general derangement of the powers of life can not long 
continue without change of structure. The symptoms indicative 
of such derangement, therefore, are the immediate forerunners of 
organic disease. If they can not be arrested they usher in the 
last stage of Indigestion. It is a curious fact, and one of the 
greatest importance in the treatment, that the organic affection 
rarely takes place in the original seat of the disease, but in other 
organs with which the stomach sympathizes, the liver, pancreas, 
spleen, mesenteric glands, lower bowels, heart, lungs, brain, &c, 

Thus, when the body is examined after death, the patient is 
said to have died of disease of some of these parts, and there 
is nothing in the appearance of the organs to distinguish such af- 
fections from diseases which originate in the organs themselves. 
It is only by a careful attention to the history of the particular 
case, and to the known laws of the animal economy, that we are 
enabled to distinguish the sympathetic from the primary disease. 

With respect to those cases in which the lungs become diseas- 
ed, I attempted some years ago, in a paper which the Medico- 
chirurgical Society did me the honour to publish in the seventh 
volume of their Transactions, to point out the means of distin- 
guishing them from primary diseases of the lungs, and the pecu- 
liar treatment which the sympathetic disease requires to prevent 
its proving as fatal as that whose original seat is in the lungs. In 
the present publication I am about to enter into the subject more 
fully, and endeavour, as far as a long continued and anxious at- 
tention to the phenomena of the cases in question, and the laws of 
the animal economy will enable me, to trace the nature and the 
consequences of that affection of the centre of the system, for so 
much the stomach may justly be called, which, if neglected, pro- 
duces a general tendency to disease; that often, if I may so speak, 
fixes on some vital organ, and wholy destroys its organization. 

It is one of the curious circumstances of the progress of the 
disease we are considering, which particularly demands attention, 
that when it fixes decidely on one organ, the others are to a cer- 
tain degree, and some times wholly, relieved. The establishment 
of the secondary affections generally relieves the dyspeptic symp- 



32 OF THE SYMPTOMS 

toms; and even a secondary disease may be relieved by another 
supervening on it. 

Thus, it is not uncommon in Indigestion for the liver to suffer 
in such a manner, that it shall become enlarged and tender on 
pressure: and when the disease is distroying the texture of the 
lungs, having spread from the liver to them, for the former to re- 
cover, or nearly recover, its healthy state. Sympathetic disease, 
when completely established, seems to act on that which excites 
it, in the same way, though much more effectually, in which arti- 
ficial drains are found to do, while the sympathetic affection which 
precedes the establishment of actual disease, tends to increase the 
original derangement. Thus an extensive external disease, as I 
have witnessed, occurring in such cases, will often save the vital 
organ, even after the disease has made considerable progress in it. 

Why the spontaneous occurrence of external disease in these 
cases produces an effect which we can so feebly imitate by excit- 
ing such a disease, we can no more explain than why a spontane- 
ous sweat carries off fever, while one produced by art, and even 
by means which themselves relieve fever, often brings little or but 
partial relief; or, why a spontaneous fit of shivering is often fol- 
lowed by a hot fit and perspiration which puts a period to the 
fever, while a shivering produced by art, would hardly ever fail 
to increase it. 

To enter fully on what I have called the third stage of Indiges- 
tion, that in which it has produced organic affections, would be 
foreign to my purpose, and would lead to a consideration of a large 
proportion of all the most serious diseases to which we are subject; 
for organic affections not only vary according to their degrees, and 
the organ they affect, but according to the consequences resulting 
from them, abscess, atrophy, dropsy, &c. 

I shall in the last chapter, treat of this stage of the disease at 
such length as the nature of the present treatise admits of. On 
account of the extensive nature and great variety of Indigestiou, 
according to the sense in which I use this term, it will be the 
most distinct plan to lay before the reader the causes and treat- 
ment of the first and second stages, the symptoms of wnich have 



OP INDIGESTION. S3 

been detailed, before I enter on a more particular consideration 
of the last stage. 

Of the various forms and comparative duration of the 
different stages of Indigestion. 

The relative duration of the different stages, as well as the se- 
verity and nature of their symptoms, is very various in different 
cast- s. In some the first stage is very slowly, even when the oc- 
casional causes of the disease have been long and repeatedly ap- 
plied, changed into the second. Thus we see men of the most 
irregular habits, and others whose habits are good, but whose di- 
gestive organs are naturally weak, for many years labouring un- 
der the symptoms of the first stage of Indigestion, without the 
disease, if I may be allowed the expression, fixing on them. The 
former are greatly indebted to a natural vigour of constitution, and 
in the latter, the stomach alone is weak. In the former, parti- 
cularly when the above symptoms have been severe, when at length 
any considerable degree of inflammatory action supervenes, change 
of structure often very quickly ensues; the organs, from long con- 
tinued irritation, being, as it were, prepared for the change. 

In others, on the contrary, particularly those of a more feeble 
constitution, the second stage soon shows itself. Before the 
symptoms of the first stage have long attracted notice, tenderness 
in the epigastrium supervenes, and the pulse becomes contracted. 
In such cases the second is generally the protracted stage of the 
disease, and the patient often continues to be much harassed, and 
occasionally seriously ill, for a long time before organic disease 
is established. 

After this has taken place, the duration of the disease, in dif- 
ferent cases, is also very various, the change proceeding more or 
less rapidly according to the strength of the constitution, and other 
causes, some of which seem involved in great obscurity. But it 
may in general be observed, that the longer and to the greater de- 
gree the causes have been applied previous to the occurrence of 
organic disease, the more rapid is its progress. 
5 



34 OF THE SYMPTOMS 

The proportional prevalence of the different symptoms of Indi- 
gestion is as various as the duration of its stages. 

In the first stage, pains and other affections of the head in some, 
in others, fits of palpitation, cough, and dyspnoea, or distention and 
pains of the stomach, or flatulence and irregularity of the bowels 
are the most troublesome symptoms. The symptoms of the second 
stage in like manner, which are both more varied and more 
strongly marked than those of the first stage, in some, are chiefly 
confined to the abdomen; in others affect the other cavities, and 
the different symptoms are variously modified in different cases. 

Thus Indigestion presents itself in various forms, which in its 
progress assume more decided characters; and no cases can differ 
more from each other than those which form the last stage of this 
disease; which necessarily varies according to the organ in which 
the change of structure takes place; and it tends still further to 
perplex the symptoms, that in some cases the disease proceeds in 
more than one organ at the same time, the affection of the one 
not arresting that of the other, as we have seen often happens. 

In every stage of the disease, indeed, there is endless variety, 
and the more nearly it approaches to its fatal termination, the 
more its different cases assume the appearance of diseases which 
have nothing in common. 

With regard to the circumstances, which dispose the sympa- 
thetic disease to affect one part in preference to another, we have 
reason to believe that this is chiefly determined by different parts 
in different individuals being more liable to disease than others, 
and therefore feeling more the cause of irritation which affects 
the whole system. Thus in children, who are disposed to inflam- 
mation and subsequent effusion in the ventricles of the brain. In- 
digestion often terminates in hydrencephalus internus. From 
about fifteen to thirty-five years of age, the disposition to affections 
of the lungs is greatest, and it often produces phthisis. At a more 
advanced period, a tendency to disease of the rectum prevails, 
and in old age to affections of the heart and head, the latter how- 
ever of a different nature from those to which children are sub- 



OP INDIGESTION. 35 

ject; and we still observe the tendency of Indigestion to produce 
the disease to which the system is disposed, whatever be its seat. 

These observations seem particularly applicable to the inflam- 
mation and consequent organic affection of the feet in gout. When 
a tendency to this disease exists, it may be induced by any cause 
that produces, and for a certain time keeps up, Indigestion. In 
some the disposition to gout is so great, that it appears without 
being preceded by symptoms of derangement in the first passages; 
but in the majority of cases it is preceded by these symptoms, 
and the tendency to them seems to constitute a considerable part 
of the hereditary disposition to gout. 

The regular forms of this disease not affecting a vital part, 
tend less to derange the system in general and give more relief to 
the primary disease than most of the other symptomatic affections 
which have been enumerated, the patient often remaining well 
for some time after; and the more cautious he is in preserving the 
vigour of the digestive organs, the longer interval he enjoys. 
Hence appears the danger which attends interrupting the regular 
fits of gout, the sympathetic disease being prevented from taking 
the course which the disposition to affection of the extremities 
gives it, seizes on the part, generally an internal one, which next 
to these is most liable to disease; and on the other hand, if any 
thing so affects any of the vital parts during a fit of gout as to ren- 
der it considerably the weakest part, the sympathetic disease 
sometimes leaves the joints and seizes on the internal part, pro- 
ducing what is called retrocedent gout. It is evident that the 
risk of both these accidents will be greatest, where the powers of 
the system are most impaired. 

The connexion of Indigestion and urinary gravel particularly 
deserves attention, as it differs from the connexion of the former 
with the preceding diseases. It is not by sympathy alone that the 
Indigestion appears to excite it. I have already had occasion to 
make some observations on the states of the urine in Indigestion. 
In most cases of this disease, we have seen, there is a considera- 
ble production of acid in the first passages. This acid, as ap- 
pears from the experiments above referred to, enters the mass of 



36 OP THE SYMPTOMS 

blood, and is thrown out of the system by the skin and kidneys. 
As all other acids occasion a precipitation of lithic acid from the 
urine, when the action of the skin is impaired, the acid we are 
speaking of often passes in such quantity by the kidneys as to 
cause a deposition of lithic acid, beiore the urine leaves these or- 
gans, which there, probably in consequence of being agglutinated 
by a secretion from the internal surface of the kidney, excited by 
the irritation of the fine sand, frequently concretes into small 
masses occasioning fits of gravel. 

We have seen that a precipitation of lithic acid, after the urine 
Las stood for some time, is a frequent symptom of Indigestion. 
The gravel which often attends this disease is only a greater de- 
gree of this symptom, for it appears from the observations of the 
best writers on calculous diseases, that the calculi formed in the 
kidney are almost always concretions of lithic acid * Thus it 
seems to be, that in old age, gout and gravel often alternate, as it 
is in the intervals of the gout that Indigestion chiefly prevails, the 
affection of the joints relieving the stomach during its continu- 
ance. The duration of this relief, alter the fit, becomes less in 
proportion as the constitution has been enfeebled by repeated at- 
tacks. 

* See the pap^r above referred to in the last volume of the Transactions 
of the College of Physicians. 



OP INDIGESTION. 37 



CHAPTER II. 

OF THE CAUSES OF INDIGESTION. 



The causes of a disease are divided into immediate and re- 
mote, the changes in the body which more or less directly excite 
the symptoms, and the causes which produce these changes. 

As it is impossible to understand the operation of the remote 
causes of Indigestion, without a knowledge of the digestive pro- 
cess, our attention must, in the first instance, be directed to this 
subject. 

SECTION I. 
Of the Process of Digestion. 

It has been ascertained by the experiments of Spallanzani and 
others, that the stomach secretes a fluid capable, even out of the 
body, of converting the food into such a mass as that into which it 
is changed in the stomach, immediately before it is sent into the 
duodenum. This fact leaves no room to doubt, that it is by the 
agency of the above fluid that the food undergoes the change which 
is effected on it in the stomach; and it appears from the observa- 
tions of Mr. Hunter, that such is the power of this fluid, that it 
often corrodes the stomach itself when deprived of the vital prin- 
ciple by which it is enabled to resist its action. When to these 
facts we add, that by means of the muscular power of the sto- 
mach, the food, when duly prepared by the action of the gastric 



38 OF THE CAUSES 

fluid, is propelled into the duodenum, we state the sum of our 
knowledge on this subject. These facts, however, are far from 
affording an explanation of the process which takes place in the 
stomach. It does not appear from the observations of any of the 
authors here referred to, by what means the fluid which is secre- 
ted by it is uniformly applied to the food, nor upon what principle 
the food which is prepared for the duodenum is separated from 
the rest. 

Mr. Hunter found that even when part of the stomach itself 
had been dissolved by the gastric fluid, the food last taken remain- 
ed wholly unchanged. This fact alone is sufficient to militate 
against the idea assumed by some, that by the muscular power of 
the stomach its contents are so moved as to be continually in the 
act of being mixed together and with the gastric fluid, by which 
their uniform solution is effected. According to this view of the 
subject also, it would be difficult to account for the gradual dis- 
charge of the contents of the stomach into the duodenum. This 
intestine must either for a long time cease to receive any food 
from the stomach after every addition made to the contents of the 
latter, or receive food in every different stage of solution, an im- 
perfection in a natural process which is in opposition to every 
thing we know of the animal economy. 

My attention was particularly directed to this subject by find- 
ing from many trials, that when the eighth pair of nerves is di- 
vided in the neck of a rabit, and one portion of each nerve folded 
back,* immediately after the animal has taken a full meal, after 
a fast of whatever continuance; none but undigested food is found 
in its stomach, provided it has been allowed to live for a certain 
number of hours after the operation. Now, if, without the divi- 
sion of these nerves, the rabbit be killed after a fast of however 



* It has been found by repeated experiments, that if neither of the di- 
vided ends be displaced, some nervous influence still passes by the divided 
nerve, and that, although the divided ends be separated by a space of even 
a quarter of an inch. See the Journal of the Royal Institution, No. 23, page 
17, et seq. It was this circumstance which gave to Mr. Brodie and Mr. 
Broughton results different from those which Dr. Hastings and myself had 
obtained. 



OP INDIGESTION. 39 

many hours, some food is always found in its stomach, reduced 
apparently to the same state as that which, during the ordinary 
period of digestion, is sent to the piloric portion, except that from 
the continued secretion of the fluids ol the stomach it is mixed 
with a greater proportion of them. It would seem indeed that 
the stomach of this animal is not able so to contract as to expel the 
last part of its contents. 

When the foregoing experiment is considered it will appear 
either that the food, last received into the stomach, is never mix- 
ed with that already there, and which has more or less undergone 
the action of the gastric fluid, or if they be mixed together, that the 
stomach has the power of again separating them, retaining the 
one and propelling the other into the intestine. These facts in- 
duced me to make some experiments on a large scale, for the pur- 
pose of ascertaining with great accuracy the process which takes 
place in the stomach, without which it is impossible to understand 
the nature of the symptoms which arise from its defects. 

With this view I examined the stomachs of about a hundred and 
thirty rabbits immediately after they had been killed in the usual 
way, which is by a blow on the back part of the bead, at various 
periods of digestion. The following were the results.* 

The first thing that strikes the eye on examining the stomachs 
of rabbits which have lately eaten is, that the new is never mixed 
with the old food. The former is always found in the centre, 
surrounded on all sides by the old food, except that on the upper 
part between the new food and the smaller curvature of the sto- 
mach there is some times little or no old food. If, as we ascertain- 
ed by more than twenty trials, the old and the new food be of 
different kinds, and the animal killed before a great length of time 
has elapsed after taking the latter, the line of separation is per- 
fectly evident, so that all the old may be removed without disturb- 
ing the new food. To ascertain this point we fed rabbits on oats, 

* Inquiry into the Laws of the Vital Functions. It is hoped that the reader 
will excuse the frequent references to this Treatise in this and the last Sec- 
tions of this Chapter, because it is by facts, which appear to be ascertained in 
it, that I shall attempt some parts of the pathology of Indigestion. 



40 OF THE CAUSES 

and after making them fast for sixteen or seventeen hours, allowed 
them to eat as much cabbage as they chose, and killed them at 
different periods, from one to eight hours, after they had eaten it. 

On opening the stomachs of rabbits three or four weeks old, 
who both sucked and ate green food, we always found the curdled 
milk unmixed with the green food. Before the stomach was 
opened we could, from its transparency, see where the green food 
and where the milk lay. 

If the old and new food be of the same kind, and the animal be 
allowed to live for a considerable time after taking the latter, the 
gastric fluid passing from the old to the new food and changing, 
as it pervades it, renders the line of separation indistinct. So 
that ou a cursory view we should suppose the old and new food 
mixed together, but towards the small curvature of the stomach 
and still more towards the centre of the new food, we find it, un- 
less it has been very long in the stomach, undisturbed and com- 
paratively fresh. All around, the nearer the food lies to the sur- 
face of the stomach the more it is digested. This is true even 
with regard to the food in the small curvature, compared with that 
nearer the centre, and the food which touches the surface of the 
stomach is more digested than any other found in the same part 
of the stomach; but, unless the animal has not eaten for a great 
length of time, the food in contact with the surface of the stomach 
is in very different stages of digestion in different parts of this or- 
gan. It is least digested in the small curvature, more in the large 
end, and still more in the middle of the great curvature. 

The foregoing observations apply to the cardiac portion of the 
stomach, the food in the pyloric portion, is always found in a state 
very different from that just described. It is more equally digest- 
ed, the central parts diff ring less from those which lie near the 
surface of the stomach. It is evident, however, that all the change 
effected in the stomach is not completed when the food enters 
this portion of it, because we find it the more digested the nearer 
it approaches to the pylorus, where, being ready to pass into the 
intestine, it has undergone all that part ot digestion which is per- 
formed in the stomach. 



OP INDIGESTION. 41 

It appears, that in proportion as the food is digested it is mov- 
ed along the great curvature, where the change in it is rendered 
more perfect to the pyloric portion. Thus the layer of food lying 
next the surface of the stomach is first digested, and in proportion 
as this undergoes the proper change, and is moved on by the mus- 
cular action of the stomach, that next in turn succeeds to undergo 
the same change. # 

As the gastric fluid, to a certain extent, pervades the contents 
of the stomach, though apparently in no other way than by simple 
juxtaposition, for the arrangement of the food, above described, 
we never found disturbed; the change in each part, which in its 
turn comes in contact with the stomach, is far advanced before 
it is in actual contact with it; and consequently is soon after this 
in a proper state to be moved on toward the pyloric end. 

Thus a continual motion is going on, that part of the food 
which lies next the surface of the stomach passing towards the 
pylorus, and the more central parts approaching the surface; 
whether food is ever so digested in the small curvUure as to be 
sent to the pyloric portion without having traversed the large cur- 
vature, I have not been able to ascertain. When rabbits have 
fasted sixteen or eighteen hours, the whole food found in the 
cardiac portion, which is in small quantity compared to what is 
found in it after a fast of short duration, seems to be all nearly in 
the same state with that next the surface of the large curvature, 
the gastric fluid having pervaded and acted upon the whole, and 
is consequently, as far as we can judge, prepared to be sent to the 
pyloric end. 

It is in the great end of the stomach, where the digestion ap- 
pears to go on so rapidly, that Mr. Hunter found the stomach it- 
self dissolved, and by the most satisfactory arguments showed, 
that this is the effect of the gastric fluid after death. His obser- 
vations on this subject confirm the foregoing view of digestion, 
and show that the same process, observed in the stomach of the 
rabbit, takes place in the human stomach; for he found part of the 
stomach dissolved, while the recent food it contained remained 
6 



— 



42 OF THE CAUSES 

wholly undigested, in the case of a man who happened to be 
killed immediately after a full meal. 

This I have often observed in rabbits when they have been 
killed immediately after eating, and allowed to lie undisturbed 
for some time. On opening the abdomen, we have found the 
great end of the stomach soft, eaten through, sometimes altogether 
consumed, the food being only covered by the peritoneum, or ly- 
ing quite bare for the space of an inch and a half in diameter, 
and part of the contiguous intestines in the last case also consum- 
ed, while the cabbage, which the animal had just taken, lay in 
the centre of the stomach unchanged, if we except the alteration 
which had taken place in the external parts of the mass it had 
formed, in consequence of imbibing gastric fluid from the half-di- 
gested food in contact with it. 

We sometimes found the great end of the stomach dissolved 
within an hour and a half after death. It was more frequently 
found so when the animal had lain dead for many hours. This 
effect does not always ensue, however long it has lain dead. It 
seems only to take place when there happens to be a greater than 
usual supply of gastric fluid, for we always observed it most apt 
to happen when the animal had eaten voraciously. 

Why it should take place without the food being digested is 
evident from what has been said. Soon after death, the motions 
of the stomach, which are constantly carrying on towards the py- 
lorus the most digested food, cease. Thus the food which lies 
next to the surface of the stomach, becoming fully saturated with 
gastric fluid, neutralizes no more, and no new food being pre- 
sented to it, it necessarily acts on the stomach itself, now depri- 
ved of life, and on this account, as Mr. Hunter justly observes, 
equally subject to its action with other dead animal matter. It 
is remarkable that the gastric fluid of the rabbit, which lives 
wholly on vegetable food, should so completely digest its own 
stomach as not to leave a trace of the parts acted on * I never 
saw tl i stomach eaten through except in the large end, in other 
parts us internal membrane is sometimes injured. 

* The rabbit will often, when hungry, eat animal food very readily. 



OP INDIGESTION. 43 

Although the food is in the most digested state in the pyloric 
end, it appears both from the fact just mentioned, and several 
other circumstances, that the change is chiefly effected in the 
great end of the stomach. The food found in the pyloric end is 
comparatively dr£> while that found in the great end, if digestion 
is much advanced, is mixed copiously with the fluids of the sto- 
mach, and there is a more evident difference in the state of the 
food, before it comes into this part, and when it is ahout to leave 
it, than in any other part of the stomach. Dr. Hastings, on ex- 
amining the stomach of a woman, who had died under his care, 
found it every where in a state of ulceration, except in the great 
end, where it was healthy. The stomach had performed its func- 
tions to the last, and the state of the a-lvine discharge proved, that 
the food had been properly digested. 

If we keep in view the foregoing account of the process of di- 
gestion in the rabbit, it will be interesting to trace the effect pro- 
duced on it by depriving the stomach of a great part of its ner- 
vous influence, by dividing the eighth pair of nerves in the neck. 

The division of this pair of nerves is one of the oldest physio- 
logical experiments of which we have any account. It was per- 
formed by several of the ancients, and has been repeated by a 
great many physiologists in modern times. Valsalva is among the 
first who gave any distinct account of its effect on the stomach. 
Haller, and many others, repeated it and describe its effects on 
this organ.* 

If the animal be allowed to live for a considerable time after 
these nerves are divided in the neck and one portion of each fold- 
ed back, the food remaining in the stomach we have seen, if the 
animal has lately taken a full meal, is always found undigested, 
and nearly in the same state in all parts of the stomach, a circum- 
stance which I was at first greatly at a loss to explain. This ef- 
fect is uniform, I never saw it otherwise. Yet we must conceive, 
that at the time the animal last eats, there is some food more or 



* See a paper by Dr. Hastings, in the 21st number of the Journal of the 
Royal Instihitiotit on the effects of dividing the eighth pair of nerves. 



« 



44 OP THE CAUSES 

less digested in its stomach, and some gastric fluid to act on part 
of that just received into it. The foregoing statements explain 
the difficulty. The division of the eighth pair of nerves prevents 
the due formation of the gastric fluid; but the animal still living, 
and the motions of the alimentary canal being ipdependent of the 
nervous influence,* the usual motions of the stomach continue and 
send onwards into the duodenum, all the food which is digested, 
and consequently capable of applying to the stomach that stimu- 
lus, which excites its natural motions. 

Thus it is evident, that the undigested food must at length come 
into contact with it. As soon as this happens the usual secretions 
not being supplied to produce the proper change in the food, an 
unnatural motion is excited; hence the efforts to vomit, which 
generally ensue in about an hour, an hour and a half, or two 
hours, after the division of the nerves, marking the time when the 
stomach having sent towards the pylorus its digested contents, 
begins to feel the effects of undigested food coming into contact 
with it. To these efforts to vomit we must ascribe the circum- 
stance of food being generally found in the oesophagus when an 
animal dies from the division of the eighth pair of nerves, for food 
is found there although it is not allowed to eat after the operation. 
If the animal be allowed to eat after the operation, the efforts to 
vomit almost immediately ensue, the food, as is evident from the 
way in which it enters the stomach, directly coming in contact 
with some part of the small curvature. 

Thus we see the cause of the efforts to vomit which follow the 
division of the eighth pair of nerves; and why, if the animal 
be allowed -to live for a certain time after the operation, nothing 
but undigested food is found in the stomach. It also appears from 
the same circumstances, why the stomach is generally more dis- 
tended than usual after the eighth pair of nerves have been di- 
vided, particularly if the animal had been allowed to eat after 
the operation, all the food not digested by the gastric fluid present 

* Experimental Inquiry, Chap. 6. 



OP INDIGESTION. 45 

before the division of the nerves, remaining in the stomach, and 
swelling from the heat and moisture.* 

From all that has been said it appears, that the process which 
the food undergoes in the stomach is that of being formed into a 
mass, in appearance nearly homogeneous; that this process takes 
place only on or near the surface of the stomach, and that, in 
proportion as the food there situated undergoes the necessary 
change, Jt is by the muscular power of the stomach moved on- 
wards towards the pylorus, making room for that which next suc- 
ceeds, till the whole contents of the stomach have undergone this 
process, the digested contents being regularly discharged into the 
duodenum, as they arrive at the pylorus, till most, and in some 
animals, all the contents of the stomach are thus removed into that 
intestine; from which, after they have for some time been detain- 
ed there, and mixed with the bile and pancreatic fluid, they are 
continually passing into the adjoining parts of the canal. 

When the gastric fluid has not a constant supply of fresh food to 
neutralize it, it is capable, as appears from what has been said, of 
corroding the stomach itself,, after the vital principle of this organ 
is extinct; .>cra which it appears probable, that the uncombined 
gastric fluid may produce some effect on the coats of the stomach 
during life, and various facts would lead us to suppose that the 
sensation of hunger arises from the action of this fluid. A sup- 
position which seems to be confirmed by the following experiment, 

A person in good health was prevailed upon to abstain from 
eating for more than twenty hours, and further to increase the ap- 
petite by more exercise than usual. At the end of this time he 
was very hungry, but instead of eating, excited vomiting by drink- 
ing warm water, and irritating the fauces. The water returned 
mixed only with a ropy fluid such as the gastric fluid is described 
to be by Spallanzani, or as I have myself obtained from the sto- 
mach of a crow. After this operation not only all desire to eat 
was removed, but a degree of disgust was excited by seeing others 
eat. He, however, was prevailed upon to take a little milk and 

* I have sometimes, but very rarely, seen a small quantity of undigested 
food in the duodenum. 



46 OF THE CAUSES 

bread, which, in a very short time, ran into the acetous fermenta- 
tion, indicated by flatulence and acid eructations. 

It seems an inference from this experiment, that the pains 
caused by hunger may be prevented by constantly exciting vomit- 
ing; and the death, which arises from it, converted into that from 
inanition, which only proves fatal after the lapse of some weeks. 
People live for weeks without food in fevers, where there is no 
secretion of gastric fluid. 

It would appear then that one of the uses of the gastric fluid 
is, by the action on the coats of the stomach, to remind us when 
a supply of food is necessary. 

We have reason to believe from the result of the foregoing 
experiment, as well as from other circumstances, that in man 
the stomach is capable of propelling the whole of its contents 
into the duodenum. In a case of Indigestion, I saw orange juice 
which had remained on the stomach for twenty-four hours, brought 
up by vomiting, unmixed with any thing, and apparently little, if 
at all, changed. In this case there was no appetite, and no se- 
cretion of gastric fluid. 

Having traced the different steps of the pi$cess of digestion in 
the healthy stomach, we are better prepared to understand the 
operation of the causes which disturb it. 

SECTION II. 

Of the remote causes of Indigestion. 

In considering the remote causes of this disease, the attention, 
we shall find, must be as much directed to the sympathy of the 
alimentary canal with other parts of the system, as in enumerat- 
ing its symptoms; for as the whole system is essentially influenced 
by the affections of that canal, and some parts peculiarly so; in 
like manner it is influenced by affections of the system in general, 
and particularly of those parts. The remote causes of Indiges- 
tion, therefore, may be divided into those which act directly on 



OF INDIGESTION. 47 

the stomach and intestines, those which act on other parts, and 
those which affect the whole system. 

It may be proper here to call the reader's attention to a circum- 
stance which greatly influences the phenomena of diseases, and, in 
particular, tends to render them protracted and difficult of cure. 
The affections, whether primary or secondary, of parts which 
sympathize, influence the state of each other. Thus sympathetic 
affections, provided they have not been converted into actual dis- 
ease of the part, in which case, we have seen, they relieve the 
original disease, become causes which support and aggravate it. 
The debility of the skin, for an example, occasioned by Indiges- 
tion, so reacts on the digestive organs, as to increase the disease 
of the stomach Similar observations apply to the sympathetic 
affections of the liver, the brain, &c, produced by the diseased 
state of the stomach; and the disease is farther aggravated by the 
increase of general debility caused by these affections. It is thus 
that the evil increasing, if I may be allowed the expression, in a 
geometrical ratio, and not by simple addition, the whole powers 
of the system, in severe attacks of disease, often sink with a ra- 
pidity which at first view appears unaccountable. We shall find 
these facts strikingly illustrated in considering the causes and 
treatment of Indigestion. 

It is evident from what has been said of the function of the 
stomach, that it may be deranged in two ways; either by causes 
affecting its secreting power, so that the proper chemical change 
is no longer effected in the food; or by such as debilitate its mus- 
cular power, so that the food, though properly prepared, as far as 
it is brought into contact with proper parts of the stomach, is nei- 
ther duly so brought, nor regularly propelled into the duodenum. 

It appears from the experiments related in the Inquiry into the 
Laws of the Vital Functions above referred to, that the muscular 
fibre, though independent of the nervous system, may be influ- 
enced through it. It follows, therefore, that the muscular fibres 
of the stomach may not only be affected by causes acting directly 
on them, but by such as act through the medium of their nerves. 

Among the chief causes of Indigestion, which act directly on 



4S OF THE CAUSES 

the muscular fibres of the stomach, are narcotic and other often* 
sive substances received into it. I have found, that although 
opium applied to the external surface of the alimentary canal and 
__ heart, produces no sensible effect on their muscular power, appli- 
ed to their internal surface it produces the same effect as when 
directly applied to the muscular fibres themselves;* impairing 
their power, unless the quantity be extremely minute, and instant- 
ly destroying it if the quantity be considerable. 

It may be questioned whether the opium pervades the fine in- 
ternal membranes of these organs and acts directly on their mus- 
cular fibres, or affects these fibres through the nervous extremi- 
ties distributed on this membrane. This is a question of little 
importance. I consider it as acting immediately on the muscu- 
lar fibres, because its effect is the same as when directly applied 
to them, and different from what it is when it acts evidently on 
the nerves themselves; and we know that the bile is capable of 
transuding through the coats both of the gall bladder and intes- 
tines. 

It is probable that other offensive substances received into the 
stomach, tobacco, distilled spirits, strong peppers, those of an acid 
or putrid nature generated in the stomach itself, &c, may also in 
the same way immediately affect the muscular fibres. All these 
substances, however, as will presently appear, otherwise influence 
the state of the stomach. We have reason to believe that the 
reception of large quantities of very warm or very cold fluids 
also directly affect these fibres. It is not uncommon for a fit of 
Indigestion to be induced by taking suddenly considerable quan- 
tities of iced fluids. Violent and repeated vomiting also debili- 
tates the muscular fibres of the stomach. But of the causes 
which immediately affect them, the most frequent and powerful 
is morbid distention. We know that the muscular power of the 
stomach, rectum, and bladder, and we have reason to believe 
that the same observation applies to the heart and other similar 

* inquiry into the Laxn of the Vital Functions. Page 133, et seq. Second 
edition. 



OF INDIGESTION. 49 

cavities, may for the time be wholly destroyed by over distention. 
The stomach may be so distended that the most powerful emetics 
will not excite vomiting,* notwithstanding the muscles sympa- 
thetically excited in this operation, those of the abdomen and 
diaphragm, are thrown into strong and repeated action; one 
among many proofs, that however necessary the action of these 
muscles in vomiting, it is by that of the stomach itself that its 
contents are rejected. The abdominal muscles excite the action 
of the stomach in this operation, in the same way that the same 
action ot these muscles, though sudden and powerful, excites the 
bladder and rectum. So perfectly the same indeed are these ac- 
tions, that if the bladder and rectum are sufficiently distended at 
the time of vomiting to be effectually excited, their contents also 
are discharged, unless retained by a voluntary act exciting their 
sphincters. In all these instances the action of the hollow mus- 
cle is excited by being pressed against its contents by the abdo- 
minal muscles and diaphragm. 

The most common cause of morbid distention of the stomach > 
is eating too fast; for the appetite only subsiding in proportion as 
the food combines with and neutralizes the gastric fluid, previ- 
ously in the stomach, when we eat too fast, time is not given for 
it to combine with that part of the food which is presented to it, 
till so much is taken that the whole gastric fluid, which the sto- 
mach is capable of supplying during the digestive process, is not 
sufficient to effect the due alteration on the food; whereas when 
we eat slowly, so that a proper time is given for the above com- 
bination to take place, the appetite abates before the stomach is 
overcharged:' for while digestion goes on, and the gastric fluid is 
only supplied in proportion as fresh food comes in contact with the 
coats of the stomach, it combines with the food as it is formed 
and never excites the appetite. 

Every one has occasionally observed that if his meal is inter- 

* The reader will find some good observations on this subject, and cases 
illustrative of them, under the head of Gasti-itis, in Eller's Work Be cog et 
Cur. Morbis. I also beg- leave to refer him to my treatise on Symptomatic 
Fevers, page 131. Fourth edition. 
7 



3V OF THE CAUSES 

| rupted for ten or fifteen minutes after he has eaten perhaps not 
more than a third of the usual quantity, he finds that he is satisfi- 
ed. The gastric fluid which had accumulated has had time to 
combine with, and be neutralized by, the food he had taken. It 
is for the same reason that a few mouthfuls taken a little before 
dinner will often wholly destroy the appetite, especially in deli- 
cate people, in whom the gsstric fluid is secreted in small quan- 
tity, or of a less active quality. Frequent interruptions in eating 
would be injurious, because we should thus be prevented taking 
the proper quantity of food, for digestion seems chiefly performed 
by the fluid which is secreted, as fresh food comes in contact with 
the stomach; and the time, which that which has accumulated 
requires for its neutralization, which of course must be more or 
less according to the accumulation which has taken place, that 
is, generally speaking, according to the length of our fast, is the 
proper measure of the quantity which ought to be taken, provid- 
ed we continue to eat, without devouring, our food. 

Another frequent cause of over-distention of the stomach is 
high seasoning and great variety of food, or such as particularly 
pleases the palate, by which we are induced to eat after the appe- 
tite is satisfied; or by the stimulus of the high seasoning a greater 
supply of gastric fluid than the food calls for is excited, and thus 
the appetite prolonged. This seems in particular to be an effect 
of wine drank during dinner. This practice, although it occa- 
sions less immediate inconvenience than eating too fast, often, if 
carried very far, by the preternatural excitement of the stomach, 
at length impairs its vigour. It is not uncommon in those who 
have greatly indulged in the pleasures of the table, to find the sto- 
mach enlarged, and its fibres sensibly relaxed. 

The degree of distention which the stomach undergoes also de- 
pends much on the kind of aliment. All food appears to swell 
more or less after it is received into the stomach; some kinds more 
than others, and of course that which is most difficult of diges- 
tion cet. par. swells most; both because it is digested and remov- 
ed from the stomach most slowly,* and because that which most 

* See what was said in the last Section of the Nature of the Digestive 
Process. 



t 



OF INDIGESTION. 51 

resists the action of the gastric fluid is most apt to run into fer- 
mentation. In considering the treatment, I shall have occasion 
particularly to point out the diet most easy of digestion. 

It is not by its effects on the muscular fibres of the stomach 
alone, however, whether acting directly on those fibres, or through 
the intervention of their nerves, that over-distention tends to pro- 
duce Indigestion. Its operation on the nerves of the stomach them- 
selves is equally injurious. It is by this effect that it produces 
that peculiar pain, restlessness, and sense of oppression, which 
attend an over-distended stomach. Such irritation of the nerves 
of a secreting surface can not exist without affecting its secreting 
power.* The gastric fluid becomes less fitted for its functions, 
and thus the distention is increased, and other evils induced. 
The contents of the stomach not being duly changed, acquire 
morbid properties, and the various symptoms detailed in the first 
chapter supervene. 

When morbid distention of the stomach and its consequen- 
ces frequently recur, the powers of this organ are weakened, and 
the debility sooner or later, extends to the other organs concerned 
in the digestive process. 

But morbid distention is only one among many causes which 
may derange the nervous power of the stomach, and thus vitiate 
its secretion. It is probably in this way, in part, that many of 
the causes which have been mentioned operate. Others appear 
to make their impression wholly on the nervous system, only se- 
condarily affecting the muscular fibres of the stomach; violent 
passions, particularly grief and anxiety; too long application to 
business, severe study, and excessive venery. Strong impressions 
of the mind often instantly destroy the appetite by occasioning 
such a secretion of gastric fluid, as, not possessing healthy pro- 
perties, at once itself fails to apply the due stimulus to the stomach, 

* It appears from experiments detailed in An Inquiry into the Laws of 
the Vital Functions > to which I have frequently had occasion to refer, and in 
The Journal of the Royal Jnstitutiori, that the nervous influence is immedi- 
ately essential to the changes which constitute secretion. I beg leave to 
refer the reader to papers on this subject, which the Editor of the above 
Journal did me the honour to publish in the eighteenth, twenty-first, and 
twenty-third numbers of that work. 



52 OF THE CAUSES 

and tends to vitiate the effect of that which had been previously 
secreted. 

Indigestion sometimes arises from mechanical pressure, either 
of the stomach itself, or other p^rts of the alimentary canal from 
tumours or indurations of neighbouring parts, or from extraneous 
bodies lodged in any part of the canal. These causes are com- 
paratively rare, and consequently not to be inferred, except from 
circumstances which unequivocally point out their existence. 

Other causes have a more complicated operation, not only di- 
rectly affecting the powers of the stomach, but influencing it at 
the same time by their operation on other organs, with which it 
particularly sympathizes. In intoxication, the stomach not only 
suffers from the morbid stimulus of the intoxicating fluid, but in 
consequence of its effects on the brain. Similar observations 
apply to a moist, cold, and variable atmosphere. The stomach 
\ not only suffers by the general debility and relaxation induced on 
. the nervous, and, through it, on the muscular system; but also by 
the peculiar effects of such an atmosphere on the office of the skin. 
Thus, too free a use of calomel and other medicines which pow- 
erfully affect the abdominal secretions, not only injures the sto- 
mach by their direct effect on this organ, but by the disorder ex- 
cited in parts with which it immediately sympathizes. 

Some causes of Indigestion affect the stomach chiefly by sym- 
pathy. The principal of these are various affections of the bowels, 
the most common long-continued constipation. We find instan- 
ces of the same kind in the Indigestion produced by diseases, and 
even accidents affecting the head; by stone in the bladder, &c. 

So extensive, indeed, are the sympathies of the stomach, that 
whatever greatly disorders the function of any important organ 
may be ranked among the causes of Indigestion; its tendency to 
produce this disease being proportioned to its degree, and the de- 
gree of sympathy which exists between the stomach and the part 
primarily affected. 

It seems chiefly by their effects on the system in general, that 
indolence, and debility arising from long disease and other causes, 
not unfrequently prove the exciting cause of Indigestion. 



OP INDIGESTION. 53 

All the exciting causes of this disease, applied in a less degree, 
act as pre-disposing causes. 

Among its pre-disposing causes must be ranked variable wea- \ 
ther. The influence of the spring, indeed, seems often to act as 
the exciting cause in the pre-disposed, and, from its tendency to 
induce the inflammatory diathesis, particularly disposes to the 
symptoms of the second stage, in those who have for some time 
laboured under the disease. The latter may also be said of tak- 
ing cold, and all other causes of inflammation. 

The period of life from puberty to about thirty, and old age, 
and in some an hereditary disposition, also pre-dispose to indiges- 
tion. It is common to find the descendants of those who have 
suffered much from Indigestion labouring under this disease. 
Much has been said of the nature of hereditary disease; all that 
is necessary for us to know, is the fact, which can not be disput- 
ed, that those parts which were most liable to disease in the pa- 
rent, are likewise found so in the children; but neither is this uni- 
versally the case, nor does the disease necessarily take place when 
the disposition to it exists. 

SECTION III. 

Of the immediate causes of Indigestion. 

The immediate causes of a disease are the states of body in- 
duced by the remote causes, and from which all the symptoms 
more or less directly arise. A knowledge of these causes is of 
the greatest importance in conducting the treatment of the disease. 
Where we are altogether ignorant of them, the treatment is found- 
ed either on the simple principle of employing the same means 
which have formerly proved useful, or on our general knowledge 
of the laws of the animal economy. It is only in proportion as 
we are acquainted with the immediate causes of a disease, that 
our endeavours can be directed to restore the due functions of the 
parts affected; and in the instances, in which, after having long 
treated diseases on the vague principles, which are our only guides 



54 OF THE CAUSES 

when the immediate causes are wholly unknown, we have at 
length arrived at a knowledge of these causes, we perceive that 
many parts of our former plans were superfluous, and not a few, 
although affording some present relief, injurious. 

In angina pectoris, for example, before it is known to depend 
on an obstructed circulation through the heart, the stomach was 
oppressed with a constant succession of anti-spasmodic medicines, 
because the symptoms are similar to those, which we know, from 
the general laws of the animal economy, spasm of certain parts 
necessarily produces; and the disease was increased by warm 
stimulating medicines which the debility, necessarily attendant on 
the state of the circulation, seemed to call for. 

As soon as dissection unfolded the nature of this disease, it was 
evident that anti-spasmodics, however they might relieve certain 
symptoms, and consequently be proper for immediate relief, could 
do little towards preventing the recurrence of the attack; and 
that all powerful stimulants, by increasing the flow of blood to the 
heart, already incapable of duly transmitting the usual quantity, 
serve only to hasten the fatal termination. 

In endeavouring to trace the immediate causes of a disease, 
there are two objects which demand attention, the change produc- 
ed in the seat of the disease by its remote causes, and the manner 
in which this change produces the symptoms. Without a know- 
ledge of the first of these, our principles of treatment must be 
vague; without that of the other, they can not be adapted to the 
particular cases under treatment. To recur to the disease just 
mentioned; till we knew that angina pectoris from the difficulty 
with which the blood is transmitted through the heart our only 
principle of treatment was to relieve the most urgent symptoms; 
and now that we are acquainted with this cause, if we could not 
distinguish what symptoms immediately depend upon it, and what 
are secondary, arising from sympathy and peculiarity of constitu- 
tion, our plans of treatment, it is evident, could not be suited to 
individual cases. 

The first part of the subject has already been considered. It 
is evident, from what has been said in the first and second sec- 



OF INDIGESTION. 55 

tions of this chapter, on the one hand, that the causes of Indiges- 
tion must necessarily affect either the muscular or nervous power 
of the stomach, or both, on which we have seen its function de- 
pends; and, on the other, that all the causes above enumerated 
are evidently such as influence them. In considering the remain- 
ing part of the subject, the manner in which debility of the mus- 
cular and nervous powers of the stomach produce the symptoms 
of Indigestion, I shall in the first place, consider those of the first, 
and afterwards those of the second stage of this disease. 

Little need be added to what I have already had occasion to 
say of the symptoms which are confined to the stomach itself. 
As the food can only be regularly propelled into the duodenum by 
the due action of muscular fibres of the stomach, it is evident 
that, if this fails, oppression and distention must ensue; and if 
the due secretion of the gastric fluid depend on the healthy state 
of the nervous influence of the stomach, its properties must be af- 
fected by any cause disordering this influence, and it will conse- 
quently fail to produce the due change on the food. 

As it appeared from what was said above, that the causes af- 
fecting the muscular power of the stomach by the derangement 
which every morbid affection of this power occasions in the diges- 
tive process, soon affects the nerves of that organ; it may now be 
observed, that all causes affecting the nervous power of the sto- 
mach, independently of the direct action of the nervous on the 
muscular power, by preventing the food from being formed into 
that substance which is the natural stimulus to the muscular fibres 
of the stomach, enfeebles their action; which we have seen is 
wholly prevented, if the cause affecting the nerves be so powerful 
as entirely to prevent the due change on the food, as happens 
when the eighth pair of nerves is divided, and one portion of each 
folded back. The morbid distention and undigested food thus 
constantly applied to the surface of the stomach, still increase the 
debility of both nervous and muscular powers. So complicated 
is the operation even of those causes of disease, which at first view 
appear the most simple. 

The manner in which a morbid affection of the muscular or 



56 OF THE CAUSES 

nervous power of the stomach produces the symptoms of Indiges- 
tion affecting distant parts, is by no means so evident. The first 
question which arises is, Why does the influence of affections of 
the stomach, and other vital organs, extend through ail parts of 
the system, while the powers of the organs of sense, parts of equal 
sensibility, may not only be deranged, but wholly destroyed, 
without affecting the function of any other part? It may be said, 
because the latter are not organs essential to life. This reply, it 
is evident, relates to the final, not the efficient, cause; and only 
suggests other terms in which the question may be put. I need 
hardly observe, that I here speak of the function of the organs of 
sense, not of the powers which sustain them. These are as much 
vital powers as those of the stomach. If the sentient extremities 
of the nerves of the eye or ear be deranged by electricity, for ex- 
ample, sight or hearing are lost, but there the evil ends. If those 
of the stomach be so deranged, with the function of the stomach 
every other function of the system is lost; not in consequence of 
the failure of the digestive process, but instantly. If, instead of a 
chemical, we employ a mechanical agent, — a sudden blow, for 
example, the same difference of effect is observed. On the cause 
of this difference, whatever it be, it is evident that many of the 
symptoms of Indigestion depend, for the effects of the various 
states of the stomach, in the different stages of this disease, are 
instantly propagated to the most distant parts of the system. We 
see the extremities become hot or cold, moist or dry; the func- 
tions of the brain or heart immediately fail, and as quickly revive; 
according to the changes which are going on in the stomach, and 
the degree in which the nerves of this organ are affected by them. 

So great is the power of the sympathy which exists between 
different parts of the system, not only in modifying, but in produc- 
ing the symptoms of disease, that it is a point of no small conse- 
quence to ascertain by what laws it is regulated. 

It has been an opinion from the time of Willis, that the sympa- 
thy which exists between different parts, depends on the connex- 
ions in the course of their nerves; and this opinion is still main- 
tained by some of the best writers; but when we consider to what 



OP INDIGESTION. 57 

inferences it leads, we shall pause, I think, before we give it our 
assent. It is known that the nerves convey impressions to and 
from the brain, to which we owe feeling and voluntary power. 
If we compress or divide the nerves of a limb, so as to cut off its 
communication through them with this organ, its sensation and 
voluntary power are lost. But we have no reason to believe, 
from the usual phenomena of the nervous system, that an impres- 
sion made on the extremities of a nerve will, in its progress to the 
brain, so affect any other nerve, with which it may communicate, 
as to influence its extremities. 

The first objection which presents itself to this explanation is, 
that is an unnecessary one. All nerves convey impressions to 
the source of nervous influence, and every nerve is capable of 
being influenced by this source. These are acknowledged facts, 
and they are capable of explaining the phenomena in question. 
It is possible, however, that some collateral facts may prove, that 
the former is the just explanation. Is it found that parts never 
sympathize unless their nerves are connected in their progress? 
Do parts, whose nerves are most connected, most sympathize? 
A crowd of facts reply to these questions. What connexion of 
nerves exists between a vital organ and the skin which covers it, 
between the liver and the ligaments of the shoulder, between the 
viscera of the abdomen and its parietes, the stomach and the 
cartilages of the ribs, &c? Why does inflammation of the pleura 
of the ribs spread as readily, or nearly so, to that of the lungs, 
which is only in contact with it, as to that in continuation with it, 
which is supplied from the same branches both of nerves and ves- 
sels? Why is inflammation of the parietes of the abdomen, or of 
any part of the bowels, in like manner, as readily communicated 
to the part in contact with it, however little their nervous com- 
munications, as to that with whose nerves the nerves of the af- 
fected part most freely communicate? 

These and various similar facts, as far as I can judge, leave no 
room to doubt that nerves sympathize only from their connexion 
in their common source, and that the numerous connexions we 

observe in their course are onlv useful in the same wav with the 

8 



58 OF THE CAUSES 

ganglions and plexuses, which may be proved by direct experiment 
to enable the influence, descending from that source, to pass from 
one nerve to another, so that one may partake of that which is 
conveyed by many, a power which, it may also be shown, is ne- 
cessary to the continuance of life.* That the phenomena of sym- 
pathy depend on changes in the source of nervous influence,! 
would appear, I think from the fact alone, that sympathetic feel- 
ings still continue to be referred to a limb which is lost; because 
this seems to be a law of general application, at whatever part 
the separation takes place. 

If we compare the foregoing facts with the result of experiments 
which prove, that the vital organs are supplied with nervous in- 
fluence from every part of the brain and spinal marrow 4 while 
the organs of sense derive theirs only from particular parts of them, 
it seems a necessary consequence, that the one set of organs can 
not be injured without influencing every part of the system, while 
in injuries of the other, only those parts of the general source of 
nervous influence, from which their own nerves arise being af- 
fected, the evil extends no farther. 

It appears from what has been said, that juxta-position is one 
of the most powerful causes of parts partaking of the affections 
of each other. We see textures of the most dissimilar nature, 

* Experimental Inquiry, Part II, Chapters 4, 5, 7. Sect. 2; and Chapter 9. 

-j- I am happy in being- able, in confirmation of the above position, to re- 
fer to a very able paper by Mr. Charles Bell, in the Philosophical Transac- 
tions of this year, entitled, " On the Nerves; giving an account of some expe- 
riments on their structure and functions, which lead to a new arrangement of the 
system," which has appeared since the publication of the first edition of this 
treatise. In the above paper, Mr. Bell has pointed out the interesting' fact, 
that some of the nerves which supply those muscles of voluntary motion, 
which sympathize with affections of the lungs, have their origin near that 
of the eighth pair: thus readily accounting for sympathies which have been 
generally ascribed to the connexions of the great sympathetic with other 
nerves; an explanation which wholly fails to account for those sympathies 
affecting- only certain muscles. 

I would take the liberty of suggesting that the above nerves, on the 
functions of which Mr. Hell has thrown so much light, should be named 
pnemo-gastric, instead of respiratory, for I think Mr. Bell will, on farther 
consideration, admit that the muscles in question equally sympathize with 
the stomach, and other abdominal viscera, as with the lungs; and we knew 
that the eighth pair of nerves bestows its influence on the latter as well as 
the former organs. 

t Experimental Inquiry. Part II, Chap. 9. 



OF INDIGESTION. 59 

receiving their nerves and vessels from the most distant sources, 
immediately partaking of each other's affections if they lie together. 
Inflammation of the skin of the chest often spreads to the inter- 
costal muscles, to the pleura of the ribs, to that of the lungs, 
to the lungs themselves. The same observations apply to the 
other cavities, for the interposition of bone itself does not always 
prevent this progress. This well-known fact is often of great 
consequence, in tracing the causes and explaining the phenomena 
of diseases. We shall find it so in the disease before us. 

When the cause of injury applied to the vital organs is very 
great, as in the cases above mentioned, all parts of the system are 
equally affected, the power of all being immediately destroyed. 
But when the cause is comparatively slight, the effect on the parts, 
which most sympathize with these organs, may be considerable; 
while on others it is hardly to be observed. Thus the effects of 
irritation of the stomach appear in the liver, the skin, the head, 
when they are not to be perceived in other parts; but as the dis- 
ease increases, as we find from the above enumeration of its symp- 
toms, they become sensible in every part. 

It appears from the experiments related in the seventh chapter 
of the above Experimental Inquiry, that any diminution of the ex- 
tent of the organs which supply the nervous influence, affects the 
state of secreting surfaces, and impairs the temperature: and Mr. 
Brodie observed similar effects, particularly with respecttothe tem- 
perature from powerfully debilitating causes affecting these organs. 
It can not, therefore, seem surprising, in derangement of the di- 
gestive organs, which so greatly debilitates the powers of the 
nervous system, and which when excessive, we have seen, is even 
capable of destroying those powers, that diseases of other parts of 
the body, and particularly of the skin, which so eminently sym- 
pathizes with those organs, should frequently arise, and be diffi- 
cult of cure. It appears from the progress of Indigestion that, 
wherever sympathetic affections are long continued, or frequently 
renewed, actual disease ensues. 

All that is here said is well illustrated by, and readily explains ? 
Mr. Abernethy's valuable observations on the constitutional origin 



60 OF THE CAUSES 

of Local Diseases, He found that many wounds, which resisted 
all the means which the surgeon could employ, were attended 
with a disordered state of the digestive organs, and yielded readily 
when the due performance of their functions was restored; nay, 
that many wounds and other local diseases had no other origin 
than the states of health which attend irritation of the stomach 
and bowels. 

It is also to be observed, that the failure of nervous power ap- 
pears more readily in some of the nervous functions than in others. 
In Indigestion, before the other functions of the surface are much 
impaired, the patient complains of a sense of cold; and when by 
degrees, the failure of these becomes apparent, the sensation of 
cold, an actual reduction of temperature, and a less than natural 
ability to resist its extremes, still continue to form a predominant 
feature of the disease; for we have seen that dyspeptics are as 
unable to bear extreme heat as cold. 

All this we still find strikingly illustrated by the operations of 
nature in other cases. It appears from the observations of Mr. 
Guthrie, in his work on Gun Shot Wounds, that when the nerves 
of a limb are injured, all its functions are impaired. It is more 
liable to ulceration than a sound part. Inflammation does not 
take its usual course in it, and wounds in it heal with greater dif- 
ficulty than usual. A diminution of temperature, however, and 
an inability to resist changes of temperature, he observes are, from 
the first, the most striking features; and the limb remains below 
the natural degree for months, or even years, if the nervous influ- 
ence is not perfectly restored. 

The preceding observations show, not only that those symp- 
toms of Indigestion which affect parts at a distance from the sto- 
mach, may arise from any other cause lessening the power of the 
nerves, whether acting as affections of the stomach do, on the 
whole nervous system, or only on the nerves of the parts chiefly 
affected; but that the order and general character of the symptoms, 
thus produced, are the same as when they arise from Indigestion; 
pointing out, in a striking manner, the similarity of their cause. 

When the whole of the facts which have been laid before the 



OF INDIGESTION. 61 

reader, in this and the preceding sections, are kept in view, it 
seems easy to point out in what way the remote causes of Indi- 
gestion operate in producing all the symptoms of what I have 
called the first stage of this disease. The debility induced by 
these causes on the muscular and nervous powers of the alimen- 
tary canal, on the one hand, by preventing the due change on the 
food, and its due discharge into the duodenum, and progress 
throughout the rest of the canal, produces the symptoms which 
immediately arise from undigested food; and on the other, either 
by its direct effects in the stomach and bowels, or through the ir- 
ritation of the undigested food and vitiated secretions, excites the 
nervous derangements which affect these cavities themselves, or 
other parts with which they sympathize. 

But in the second stage of the disease we see a change which 
can not be referred to either of these heads, I mean, the occurrence 
of tenderness in a certain part of the epigastric region above de- 
scribed, which hardly ever fails to supervene in protracted cases; 
and when considerable, to be accompanied with a pulse which 
will be found more or less hard, if examined in the way above 
pointed out,* and some of the other indications of fever which 
have been enumerated. I am now to lay before the reader such 
facts as seem to throw light on the more immediate cause and 
nature of those symptoms, which we shall find greatly influence 
the treatment of this disease. 

I have had occasion to call the reader's attention to man? facts 
which prove, that irritation is often felt in a part at a distance 
from that to which the irritating causes are applied. Now, 
whatever may be said of the way in which any cause of irrita- 
tion affects the part to which it is applied, it is evident, that it 
can only affect a distant part through the medium of its nerves. 
Thus, when worms in the intestines produce pain of the chest, 
dyspnoea, &c, we know that these symptoms arise through the me- 
dium of the nerves, and by watching their effects we are enabled 
to determine, what the effects of mere irritation of the nerves are, 

* Chap. I, page 17, et seg. 



6i OF THE CAUSES 

It appears, from what was said above, that this irritation, in 
the tirst instance, produces no sensible change in the part sym- 
pathetically affected. If the worms are removed from the intes- 
tines within a few hours after the pain, the dyspnoea, and other 
pectoral symptoms have supervened, they immediately disappear, 
and the lungs perform all their functions as well as if no s\mp- 
tom of disease had existed. But we have also seen, that ii tbe&e 
sympathetic symptoms remain for a certain time, inflammation 
of the lungs takes place, and they exhibit, on dissection, all the 
marks of this disease, suppuration and its other consequences not 
excepted. Other instances of the same kind were adduced, and 
it would be easy to multiply them.* 



* Since the publication of the first edition of this Treatise, Mr. Brodie 
has favoured me with the following- letter, containing an account of an im- 
portant experiment which he made many years ago, and some valuable 
observations, which seem strikingly to illustrate this part of the subject, 
and. which he has had the goodness, at my request, to permit me to make 
public. 

"My dear Sir, — The following are the particulars of the experiment to 
which you have alluded: 

" On the 29th of June, 1814, I exposed the nerves of the eighth pair in 
the neck of a rabbit, and by means of a fine needle, I passed a silk thread 
transversely through the substance of each nerve, in the manner of a small 
seton. The extremities of the threads were left hanging out of the exter- 
nal wound. This operation did not produce any immediate effect on the 
respiration: but at the end of twenty-four hours the animal was observed to 
breathe in a laborious and difficult manner, twenty eight times in a minute. 
The threads were withdrawn, but the removal of them occasioned no relief, 
and fourteen hours afterwards the rabbit was found dead. On dissection 
both lungs were seen loaded with blood and inflamed. The left lung was 
inflamed in the greatest degree, the surface of it being encrusted with coa- 
gulated lymph, and lymph being effused also in several places in the inter- 
tubular substance and auricles. There was a considerable quantity of serum 
in the cavity of each pleura. 

"The stomach and intestines were in a natural state, presenting no ap- 
pearance of inflammation. The gall-bladder was nearly emptied. A slight 
degree of inflammation existed in each nerve; but only at the part where 
the seton had been introduced. 

" It appeared to me that, in this experiment, the inflammation of the lungs 
might reasonably be attributed to the irritation produced by the threads on 
the nerves, by which they were supplied. A multitude of other circum- 
stances might be adduced in proof of the doctrine, that simple nervous irrita- 
tion is capable of producing local inflammation, even at a distance from the 
part in which the source of the irritation exists. A calculus passing clown the 
ureter occasions pain in the testicle; and if a certain length of time elapses 
before the calculus escapes into the bladder, this symptomatic pain is fol- 
lowed by swelling, tenderness, and no small degree of inflammation in the 
testicle. In like manner, in some cases of disease in the hip, the sympto- 
matic pain in the knee is attended at last by tenderness and puffy swelling 



OF INDIGESTION. 63 

Thus it appears that irritation of the nerves of a part may ex- 
ist for some time without any change taking place in the state of 
its circulation; and when the cause of irritation is not severe, and 
the part little disposed to disease, this may be the case for a long 
time. Pain of the shoulder often continues for months in chronic 
affections of the liver, without the shoulder becoming stiff or ten- 
der to the touch; but, it also appears, that the continuance of the 
nervous affection, sooner or later, according to its degree, and the 
tendency to disease in the part sympathetically affected, influen- 
ces the state of its vessels. The effect, which thus takes place 
in a distant part, must, of course, take place more readily in that 
to which the cause of irritation is applied. 

Now it appears from what was said in the second section of 
this chapter, that all the causes of Indigestion act either directly 
or indirectly, on the nerves of the digestive organs. 

This irritation of the nerves must sooner or later produce the 
same effects here, as in other parts, and the vessels at length par- 
taking of the disease, some tendency to inflammation must ensue. 
This is indicated by the symptoms above mentioned, a tenderness 
on pressure in the part affected, hardness of the pulse and other 
febrile symptoms, which under all circumstances indicate inflam- 
mation or a state approaching to it. 

As the tenderness of the epigastrium is always the first of these 
symptoms, and the others are proportioned to it, and yield, as we 
shall find, to the means which relieve it, it is evident that these 
symptoms arise from the same cause which produces it. It is a point 
of considerable importance in the. treatment, therefore, to ascertain 
the nature and seat of the affection, which occasions this tender- 
ness. 



of the latter articulation; and in many instances in which suppuration takes 
place slowly on the membrane of the brain, after an injury of the head, the 
patient becomes affected with inflammation and abscesses of the lungs, liver, 
or some other organ remote from the seat of the original malady. 

*< l have much pleasure in being able to communicate to you these obser- 
vations, in confirmation of the opinions which you have expressed and pub- 
lished on these subjects; and I am, dear Sir, yours, very truly.. 

_ i>. 0. BnoBir,,' 1 ' 

SaviUe-ro™, Oct. 26, 1821." 



64 OF THE CAUSES 

It is evident that of the different parts of the stomach, the pylo- 
rus is the one most exposed to the causes of irritation. Other 
parts experience the irritating effects of different portions of its 
morbid contents, but the pylorus is necessarily exposed to those of 
all. All must pass by this orifice. When therefore we see that, 
after Indigestion has continued for some time, a certain part of 
the region of the stomach becomes tender on pressure, we can not 
help turning our attention to this part. Now in the natural situa- 
tion of the viscera, exactly in the tender part of the epigastrium, 
the pylorus lies, with the thin edge of the liver upon and in con- 
tact with it; as I have ascertained with the kind assistance of Mr. 
Brooks, whose anatomical skill is so generally acknowledged. 

When all these circumstances are considered, can we doubt 
that it is the irritated pylorus assuming a low degree of inflam- 
mation which occasions the tenderness on pressure above describ- 
ed; and when we consider what has just been said of the influ- 
ence of juxta-position in the spreading of this disease, can we 
doubt, when we find the tenderness with some degree of fulness 
gradually extending downwards, along the soft parts on the edge 
of the cartilages of the right side of the epigastrium, as we find it 
to do in the progress of Indigestion, and at length ending in evi- 
dent enlargement and tenderness of the liver, that the affection of 
this organ, with which it is in contact, thence by degrees extend- 
ing to its other parts? Thus it is that of all the neighbouring 
parts no other so frequently partakes of this affection of the sto- 
mach. It is doubtless in the same way, that the habit of drink- 
ing spirits, which must apply so great a degree of irritation to 
the pylorus, seldom fails to produce affections of the liver. 

We have reason to believe that it is from its greater exposure 
to causes of irritation, that the pylorus itself is more subject to 
organic disease than any other part of the stomach; but the wise 
Author of our being seems to have given to a part necessarily so 
much exposed, a great power of resisting disease; so that the first 
deviations from the healthy state, which are communicated from 
it to the liver, more readily take root there, if I may be allowed 
the expression; and the structure of this organ yields to the affec- 



OF INDIGESTION. 65 

tion which that of the part, from which it receives it, generally 
resists. The liver indeed is here already disposed to disease, its 
action we have seen from an earlier period, having by sympathy, 
been influenced by the state of the stomach; and the continuance 
of diseased action, we know, disposes to disease of structure. 

I am well aware that the fulness of the right hypochondrium 
in Indigestion, even when combined with tenderness on pressure, 
does not always indicate an affection of the liver. It often, 
I believe, arises from the state of the duodenum, which fre- 
quently expels its contents with difficulty in this disease, and my 
experience corresponds with many of the observations made by 
Dr. Yeats in his excellent paper on this intestine, in the last vo- 
lume of the Transactions of the College of Physicians. 

It has been stated, in enumerating the symptoms, that the ful- 
ness and tenderness of the right hypochondrium in the early stages 
of Indigestion are often temporary. I have repeatedly seen them, 
even when they were considerable, disappear after the operation 
of a brisk cathartic. They must then arise either from a distend- 
ed and oppressed state of the duodenum, or temporary distention 
of the various vessels of the liver. To which of these causes we 
should ascribe them, the accompanying symptoms will generally 
enable us to determine. The feeling given to tiie hand by the 
distended duodenum is different from that produced by the gorged 
liver, and in the former case the chief fulness is generally lower 
^lown, and does not seem to proceed so immediately from under 
the edge of the thorax as general fulness of the liver does; so that 
even where, from more permanent debility of the duodenum, its 
morbid distention is a more constant symptom, the two cases 
may generally be distinguished. The more temporary nature of 
both these affections, with the history and general symptoms of 
the case, for the most part readily enable us to distinguish them 
from fulness and tenderness of the same region arising from or- 
ganic disease of the liver, which comes on slowly und uniformly, 
and the commencement of which, when it arises from Indigestion, 
may generally be traced to the epigastrium. 

The observations which have been laid before the reader, as 



66 OF THE CAUSES 

far as I am capable of judging, leave no room to doubt, that an 
inflammatory affection of the pylorus, excited by the passage of 
the irritating contents of the stomach for a longer or shorter time, 
according to the nature of these contents, and the greater or less 
degree of inflammatory tendency in the part, is the cause of the 
tenderness observed in the epigastrium, and which at first is gen- 
erally confined to a space not larger than a shilling; an inference 
confirmed by dissection, which often exhibits the internal mem- 
brane of the pylorus thickened in those who have suffered much 
from the disease of the digestive organs. 

It appears from many experiments detailed in the introduction 
to my Treatise on Symptomatic Fevers, and which have been care- 
fully repeated by Dr. Hastings* with the same results, that all 
the causes of inflammation act by debilitating the capillary ves- 
sels of the part, and thus allowing them to be distended by the 
vis a tergo, from which, as appears from what is said in the trea- 
tise just referred to, and last part of the Inquiry into the Laws of 
the Vital Functions, all the phenomena of inflammation seem ne- 
cessarily to arise. 

It is this debility of the finer vessels of the pylorus, therefore, 
produced by long continued irritation of its nerves, from which 
arise, in the second stage of Indigestion, the hard pulse and other 
symptoms of feverishness above enumerated, and by which, we 
shall find the successful treatment of this stage essentially influ- 
enced. 

It is a. point of great importance in the progress of disease, that 
febrile disease begins with inflammatory action, that is, debility 
and distention of the finer vessels, and their constant effect in- 
creased action of the larger ones, and at length necessarily pro- 
duces debility of the nerves; while nervous disease begins with 
the latter, and as certainly ends in debility and distention of the 
finer vessels. It seems to be this which renders the chronic in- 
flammation of organs so much more difficult of cure, and apt to 
run to derangement of structure, than the acute form of the dis- 
ease. In the former, the functions of the part are more generally 

* Dr. Hastings's Treatise on Bronchitis. 



OP INDIGESTION. 67 

injured. Its nervous power is debilitated before its vessels be- 
gin to be distended. Besides, the debility of the nerves, and that 
of the extreme vessels tend to increase each other; and unless the 
chain of diseased action can be broken by means which enable 
the vessels to recover their healthy diameter, it goes on more or 
less quickly, sometimes, if the symptoms are mild, very slowly, 
till the structure of the organ is destroyed. 

The inflammatory action in Indigestion r partaking of the 
chronic nature of the disease it belongs to, often, in the first in- 
stance, attracts so little attention, that the stimulating plan, which 
we shall find suited to the first stage, is sometimes pursued till 
organic derangement at once announces to the practitioner the 
danger of the patient, and the necessity of adopting other princi- 
pies of treatment. But as such an inflammatory state as that we 
have been considering may always, I believe, be observed to 
precede organic derangement of vital organs; and, both on this 
account, and for other reasons, appears to be its immediate cause; 
it is of the utmost consequence, in preventing that derangement, 
to watch the first appearance of inflammatory action, for it is at 
the beginning alone that it can be effectually counteracted. The 
period at which it shows itself, we have seen, is very various, a 
circumstance which has doubtless contributed to obscure this part 
of the disease. 

While the foregoing changes are going on in the solids, the 
fluids of the body must necessarily undergo corresponding devia- 
tions from the healthy state. In proportion as the flow of nutri- 
ment into the blood is lessened, the chyle itself probably more 
or less vitiated, and as the different secretions fail, the circulating 
fluids must be subject to various changes. What these are the 
present state of our knowledge makes it impossible to ascertain. 

In those who have long laboured under Indigestion in its more 
severe forms, the blood is sensibly altered in some of its properties. 
The proportion both of red globules and lymph is less than in 
health. This state of the blood must necessarily affect that of 
the fluids supplied to secreting surfaces, and from this cause also, 



68 OF THE CAUSES 

the secretions of the digestive organs must further deviate from 
the healthy state. 

In considering the mutual action of one part of the system on 
another, the state of the mind deserves particular attention in In- 
digestion. The disease itself we have seen seldom fails to render 
it anxious, irritable, and apprehensive; and this state of mind, 
which we have found ranked among its causes, can not fail to in- 
fluence its symptoms. 

When the reader reviews the various facts which have been 
laid before him relating to the operation of the remote causes of 
Indigestion, and particularly takes into the account what I have 
frequently had occasion to recal to his recollection, that the mor- 
bid states of all those parts sympathetically affected, till actual 
disease takes place in them, operate as secondary causes of the 
primary affection, both by sympathy, and by their farther weak- 
ening the general powers of the system, he will perceive how 
complicated the operation of its remote causes must be; and in- 
deed by reflecting on the nature of the animal body, the great 
variety of parts of which it consists, the different nature of these 
parts, the variety of functions necessary to produce each indivi- 
dual result, and the variety of causes which may influence each 
organ in this complicated structure, we are prepared for such a 
conclusion. 

When the motions of a clock are suspended, we find a wheel 
clogged, and readily perceive how this cause of derangement has 
destroyed the action of the machine; because its action depends 
wholly on one principle, and consequently all causes impeding 
its motion must affect this principle. But did the nature of the 
clock include many principles of action, and were the cause of 
disorder such, as might influence several or all of them, we should 
seldom finds its effect confined to the derangement of one part: 
yet, even then the effects of the offending cause would be simple 
compared to those of a cause of disease, for to bring the machine 
into a state analogous to that of the animal body, and render the 
effect of its offending causes equally complicated, its different 
principles of action must not only have some of them a direct, and 



OF INDIGESTION. 6 9 

all an indirect, dependence on each other; but besides this depen- 
dence for their actual existence, each must in a greater or less 
degree be capable of influencing every other, and in such a way, 
that the secondary affection re-acts on the part first impressed by 
the offending cause. 

In a machine so constituted, until we could trace the manner 
in which the different principles of action depend upon and af- 
fect each other, what possibility would there be of ascertaining 
the change which any cause of derangement had occasioned in it, 
and there could surely be no expectation of finding it in the dis- 
order of any one part. How vain then was the humoral patho- 
logy, and how vain that of the simple, or even of the living solid, 
although the last, which we owe chiefly to the labours of Hoff- 
man and Cullen, must be regarded as an important step towards 
a true view of the nature of disease. 

AH the parts of a living body are concerned in its diseases, and 
it is only as we advance in a knowledge of those various parts, 
and their relations to each other, that the nature of its deviations 
from a state of health can be understood. 



70 OF THE TREATMENT 



jun^ 



CHAPTER III. 



OF THE TREATMENT OF INDIGESTION. 

The treatment of indigestion, like its symptoms, may be divi- 
ded into three parts, that of the first, second, and third stages of 
the disease. The two first only, for reasons already given, we 
are here to consider. 

SECTION I. 

Of the treatment of the first stage of Indigestion. 

The first object in the cure of all diseases is to remove the re- 
mote causes as far as they still continue to operate. Among those 
of Indigestion, we have seen, that whatever occasions morbid dis- 
tention of the stomach, or irritates its surface, holds a chief place. 
It unfortunately happens, that there is a continual tendency in 
this disease to produce those causes. However well, therefore, 
we may succeed in removing them, it requires constant attention 
to prevent their recurrence. It also appears from what has been 
said, that these observations apply with almost equal force to 
some of the other causes of this disease, particularly to that inac- 
tivity of body and irritable, anxious and desponding state of mind, 
which so frequently cause, and are caused by, Indigestion. 

The first part of the treatment, therefore, which falls under our 
attention, relates to diet and exercise both of mind and body; and 
in the slighter and more recent cases a strict attention to these 
alone, or at most with the assistance of an occasional mild ape- 
rient, will often be found sufficient to effect the cure; and the 



OF INDIGESTION. Tfji 

neglect of them will, in all cases, tend to counteract whatever 
other means we employ. 

Of the diet in Indigestion, 

The objects to be kept in view in regulating the diet in this 
disease, as appears from what has just been said, are that it shall 
tend as little as possible to produce either morbid distention or 
morbid irritation of the surface of the stomach. 

Many of the regulations belonging to the first of these heads 
arise out of what was said in the section on the immediate causes 
of Indigestion. It would appear from the observations there made, 
that the appetite continues till the first food neutralizes the gas- 
tric fluid which had accumulated in the stomach and caused the 
sensation of hunger. If the patient eats with great rapidity, he 
will, during the time required for this combination, put such a 
quantity of food on the stomach as to occasion some degree of 
morbid distention, which will be greatly increased by the swel- 
ling of the food, in consequence of digestion being impeded by the 
distention; while the stomach, at the same time, for reasons above 
explained, does not, with the usual facility, propel it into the intes- 
tine. Thus it is that the feeling of distention often increases for 
some time after too full a meal, and, at length, is frequently accom- 
panied with actual pain. 

The food, when we eat too fast, is not only received into the 
stomach in too great quantity, but is swallowed without being 
duly masticated and mixed with saliva, and therefore without 
properly undergoing what may be considered the first process of 
digestion. It is thus presented to the stomach in a state, in which 
the gastric fluid pervades, and consequently acts upon it with 
more difficulty. In this way eating too fast is injurious even 
when the patient abstains from taking too much. For these rea- 
sons, to eat moderately and slowly, is often found of greater con- 
sequence that any other rule of diet. The dyspeptic, in eating, 
should carefully attend to the first feeling of satiety. There is a 



72 OF THE TREATMENT 

moment when the relish given by the appetite ceases; a single 
mouthful, taken after this, oppresses a weak stomach. If he 
eats slowly, and attends carefully to this feeling, he will never 
overload the stomach. 

Morbid distention of the stomach, however, may take place, 
although there be no error in either of these respects, if the food 
be of such a nature that the fluids of a weak stomach are unable 
to effect the necessary change on it, in consequence of which it 
runs into fermentation. 

It is evident that morbid distention, from whatever cause, 
can not exist without, at the same time, occasioning morbid irri- 
tation of the surface of the stomach. The distention itself has 
this effect, but as deranged digestion is the consequence of this 
degree of distention, it can never stop here. All undigested food, 
however small the quantity, is a cause of irritation. 

Thus the whole train of symptoms, which constitute a fit of 
Indigestion, may arise either from too large a quantity of food, 
particularly if carelessly masticated, or from food of difficult di- 
gestion, most readily of course from a combination of these cau- 
ses. It is, therefore, of great consequence, in regulating the 
treatment of this disease, to ascertain what kinds of food are most 
easily changed by the gastric fluid. This is sometimes influenced 
by peculiarities of constitution, to which no general rules will 
apply, but it is not difficult to perceive, what kind of diet is usu- 
ally best suited to a weak stomach. 

Tough, acescent, and oily articles of food, with a large propor- 
tion of liquid, compose the diet most difficult of digestion. It 
would appear that a feeble gastric fluid, as indeed we might a priori 
suppose, does not admit of being greatly diluted without having its 
powers much impaired. The diet opposite to this, then, is that 
which agrees best w r ith dyspeptics. h\ the first stage of Indiges- 
tion, a diet, composed pretty much of animal food and stale bread, 
is the best. 

If we except beef and veal, the flesh of old, in general, is more 
easy of digestion than that of young animals, on account of the 
greater quantity of mucilage in the latter. Ail mucilages are of 



OP INDIGESTION. 73 

difficult digestion. Even the vegetable mucilages, which in small 
quantity are generally grateful to the stomach, will oppress it, if 
taken very freely. They are among the things which, in vulgar 
language, are called sating, or phlegmy. Whatever produces 
the feeling known by these terms disagrees with the stomach. 

The stronger kinds of animal food, of which beef may be con- 
sidered the strongest, are most apt to excite fever. On this ac- 
count we often allow those, recovering from fever or otherwise 
disposed to it, to eat the animal mucilages, or those meats which 
contain a great proportion of them, when even mutton for exam- 
ple is forbidden. Thus animal jellies and young meats have ob- 
tained the name of light, but this only relates to the tendency to 
produce fever, for as far as digestion is concerned they are hea- 
vier than mutton, and to many stomachs than beef. A similar 
observation applies to the vegetable, compared with the animal 
kingdom; the former are less apt to excite fever, and are there- 
fore called lighter, but they are in general more difficult of diges- 
tion. 

From what it arises that mutton is to most stomachs so much 
more easy of digestion than beef, it would be difficult to say. 
Most kinds of game are of easy digestion. Fish, independent- 
ly of the heavy sauce with which it is eaten, is, for the most 
part, less easily digested than the flesh of land animals; and as it 
at the same time affords less nutriment, it is in both respects less 
proper for the food of dyspeptics; although from the white kinds 
being less apt to excite fever, they, like the animal mucilages, 
have obtained the name of light, a term whicrr*so often deceives 
with respect to what is most easy of digestion, that it is neces- 
sary to keep this explanation of it in view. 

The meat most mixed with fat, is, cet. par., most oppressive. 
It is on this account that pork and the tongues of many animals 
are of difficult digestion. For the same reason, geese and ducks 
are the most oppressive kinds of poultry. Turkey is more so 
than fowl, which, next to mutton, is, perhaps, upon the whole, 
the lightest animal food in common use, if the skin be avoided. 
Of the different kinds of game, pheasant is least easy of diges- 



7 



74 OP THE TREATMENT 

tion. The lean part of venison is, perhaps, the most digestible 
article of diet. Hare and partridge appear to be as much so as 
mutton. 

Eggs, as far as relates to a tendency to produce fever, may be 
regarded as of a middle nature between animal and vegetable 
food. It is a common opinion that they disagree with bilious 
people, that is, people labouring under Indigestion, in whom the 
disease has extended to the function of the liver. This opinion, 
in general, I believe, is ill-founded, if they are eaten soft boiled 
with stale bread. In this state, although offensive to a few sto- 
machs, they, for the most part, are easy of digestion, if the pati- 
ent confines himself to one, or at most two, and are an agreeable 
change. 

Few things are of more difficult digestion than new bread. 
This observation applies to every thing which by mastication 
forms a tenacious paste, which is not easily pervaded by the gas- 
tric fluid. So difficult of digestion is such a paste, that I have 
known more than one dyspeptic, whose stomach could only di- 
gest new bread, when it was soaked in melted butter. Here 
one of the articles most difficult of digestion, was more easily 
digested than the tenacious paste which its presence prevented. 
Even bread sufficiently old is oppressive if taken alone, and in 
large quantity, it still forms a mass not very readily pervaded. 

On the same principle, food is often rendered more indigestible 
by processes employed with a view to assist the stomach. All 
articles composed of strong jellies, and food carefully mashed are 
oppressive. The coarser division which our food undergoes in 
mastication is better suited to assist digestion. Most dyspeptics 
find, that potatoes, for example, finely mashed, although without 
any admixture, are more difficult of digestion than when properly 
masticated. During mastication the saliva is freely mixed with 
them, and a mass is formed easily pervaded. When they are 
mashed, they resist admixture with the saliva, as well as the 
gastric fluid. 

Our food is rendered more easy of digestion by simple roasting 
or boiling, provided it is not too much done. Beyond this, the 



OF INDIGESTION. 75 

art of cookery is nothing, but that of pleasing the palate at the 
expense of the stomach. There are a few circumstances under 
which it is proper to bribe a patient to eat; under ail others, the 
refinements of the cook are at variance with the objects of the 
physician. However imposing the plans of concentrating much 
nutriment in small compass may at first view appear, we may be 
well assured, that in such concentration something is taken away 
from what nature designed for our food, which is useful to us. 

It is not generally known, that the most concentrated decoction 
of beef, so far from affording much nourishment, will not, if un- 
mixed with something solid, even allay the appetite. A person 
under my care was attacked with a severe pain of the face when 
even the smallest quantity of any solid food was put on the sto- 
mach, a single mouthful of bread never failing to bring on the at- 
tack; and, as he at length refused all solid food, he was confined 
for some weeks to a strong decoction of beef; but, however strong, 
and in whatever quantity it was taken, it never relieved the calls 
of hunger, and he rapidly emaciated. 

Fresh vegetables, on account of their tendency to ferment, are, 
on the whole, injurious in Indigestion. Some vegetables, how- 
ever, are more so than others. Peas, beans, cabbage and waxy 
potatoes, I have found the worst Mealy potatoes, turnips, and 
broccoli, among the best. They should always be boiled till 
they are soft; raw vegetables of all kinds are oppressive; lettuce 
appears to be the least so. The tough, thready, and membrane- 
ous parts of vegetables are of most difficult digestion. 

Fruit are also difficult of digestion, particularly the cold fruits, 
melons, cucumbers, &c; next to these, the mucilaginous fruits, 
gooseberries, pears, &c. Apples and strawberries I have found, 
on the whole, lightest; but we more frequently find peculiarities 
in the stomach with respect to fruits than other articles of diet. 
To many stomachs the most acescent fruits, currants, mulber- 
ries, &c, are particularly offensive. All preserved fruits are \ 
oppressive, — the large proportion of sugar adding much to their 
indigestible quality. To some dyspeptics sugar is so oppressive, 
that I have known several who were obliged to abstain even 



76 OF THE TREATMENT 

from the small quantity used in tea. Most stomachs bear acids 
better than acescents. 

Bread is not the worse for being hard, provided it is properly 
masticated. All hard and tough animal food, particularly if it 
be salted, which adds to its hardness, is of difficult digestion. It 
seems to be from its hardness that smoked meat is oppressive. 
Hard and tough animal food can not, by mastication, be reduced 
to the loose pultacious form which hard bread assumes. 

There are few things in common use so oppressive as butter. 
It appears to be more so than the fat of meat. The fat of mut- 
ton is less difficult of digestion than that of beef, and the fat of 
venison less so than either. The same may be said of the fat of 
turtle, but all kinds of fat are oppressive to a weak stomach, and 
that of which we are inclined to eat the most is generally, on 
this account, the worst. We have little experience of oil in this 
country. Could I trust the result of a few instances, I should say 
that olive oil, to a stomach accustomed to it, is less oppressive 
than butter, probably than most kinds of fat. 

All oily substances are rendered more oppressive by being fried, 
as in many of our dishes; yet, such is the peculiarity observed in 
particular cases, that I have known a dyspeptic digest fried ba- 
con pretty well, who could not digest mutton; as if the strong 
stimulus of the former excited a secretion of gastric fluid, where 
the milder stimulus of the mutton failed. It seems to be on this 
principle that the stomach will often digest a little of any thing 
for which the patient greatly longs, and that the appetite some- 
times increases after we begin to eat. 

Cheese is, in general, still more difficult of digestion than 
either butter or fat. With their oily nature, it combines the 
hardness and toughness of the dry aud compressed curd, which 
is very difficult of minute division. Milk and cream, with their 
preparations, are generally oppressive in proportion to their rich- 
ness: but the same proportion of cream mixed with water is more 
digestible than milk. 

Much seasoning is injurious, both by the unnatural excitement 
"which it occasions, by which it, for the time, increases the power 



OF INDIGESTION. 77 

of the stomach, at the expense of subsequent debility; and by in- 
ducing us to eat too much. It also, like other strong stimulants, 
has a more direct tendency to induce the second stage of the dis- 
ease, 

With respect to fluids, water is evidently intended for the pro- 
per dilution of our food. As, on the one hand, we have seen the 
food may be so watery that it too much dilutes the gastric fluid; 
so, on the other, it may be so dry, that this fluid can not easily 
pervade it, and its necessary motions in the process of digestion 
are affected with difficulty * 

But these are not the only, nor do they appear indeed to be the 
principal, purposes for which we are induced to drink, which 
seems generally to be, to supply the waste of moisture occasioned 
by the various secreting surfaces, and particularly by the skin, 
which is the most extensive; hence every thing which promotes 
perspiration increases thirst. For a similar reason diarrhoea, and 
the operation of a cathartic have the same effect; and it appears 
from many facts, that there is often a rapid absorption of fluid from 
the stomach. 

In health, when the various functions are in due proportion, 
little liquid is required with the food, the inhalation by one set of 
vessels nearly compensating for the exhalation by others. Thus 
it is that the most healthy are little troubled with thirst. In In- 
digestion, we have seen it is a frequent symptom. It seems some- 
times to arise from a general failure of the secretions of the ali- 
mentary canal, from the mouth downwards, more frequently 
from irritation of the stomach, excited by the undigested food; 
for there is a false thirst, as well as a false appetite. As that 
irritation frequently induces the patient to eat when there are no 
fluids in the stomach adapted to the office of digestion, it excites 
him to drink when there is no want of fluidity in the various juices 
of the body; and when so far from there being a want of liquid 
in the stomach, it is surcharged with vitiated fluids. 

* Besides the gastric fluid, properly so called, we have reason to believe 
that the stomach, like other secreting surfaces, forms a biand fluid for the 
purpoie of defending itself to a certain degree against the irritation of its 
contents. This fluid may also be of use in promoting the necessary motions 
of the food. 



7S OF THE TREATMENT 

The drink, under such circumstances, only giving relief in 
proportion as it dilutes the irritating matter, the thirst returns as 
soon as its irritating properties again increase by its continued 
fermentation, or perhaps merely as soon as the stomach has be- 
come accustomed to the degree of relief which the last draught 
procured. In this way dyspeptics often drink vast quantities, 
greatly distending the stomach and increasing their disease. 

There is some difference of opinion respecting the propriety of 
drinking at meals It is evident from what has been said, that 
the necessity of drinking must be different under different cir- 
cumstances; but in general it is best shown by the degree of 
thirst, and there can not perhaps be a more erroneous idea than 
that, which induces some people to drink during meals, for the 
purpose, as they say, of assisting digestion, when they feel no de- 
sire for it. 

x ' Drinking water can in no other way assist digestion than by 
affording the proper degree of moisture to the food. If there be 
no thirst, we may be assured that it already possesses this degree 
of moisture, and that any addition to it will only dilute the gas- 
tric fluid, and consequently enfeeble its solvent power. I have 
often observed, that eating too fast causes thirst, the food being 
swallowed without a due admixture of saliva, the mass formed in 
the stomach is too dry. It is almost unnecessary to observe, that 
the liquid taken after food must but imperfectly answer the pur- 
poses of that mixed with it during mastication. 

The best rules, I believe, which a dyspeptic can follow, are 
not to yield to every slight sensation of thirst, and when the sen- 
sation is considerable, to take but a moderate quantity, and that 
deliberately, for it is with drinking as with eating, if he swallow 
with too great rapidity, he will take too much. 

Such appear to be the regulations respecting liquids most con- 
sistent with the nature of indigestion, when the fluid possesses no 
other properties but those of quenching the thirst. If it possesses 
other properties, other circumstances demand consideration. Both 
nutritive articles of diet and stimulants may be received in the 
liquid form. 



OP INDIGESTION. 



79 



I have just had occasion to observe, that the most nutritive 
fluid alone will neither satisfy the appetite nor afford due nour- 
ishment. When we reflect on the facts above stated relating to 
the manner in which digestion is performed in man and the ani- 
mals most similar to him, we shall easily perceive why liquids 
alone are incapable of affording sufficient nourishment. We have 
seen, that that part of the food which lies next the stomach having 
duly undergone the action of the gastric fluid, is moved onwards 
towards the pylorus, while that next in succession is in its turn 
applied to the surface of the'stomach, where it excites a further 
secretion of gastric fluid, undergoes its action, and in like man- 
ner is moved onwards towards the pylorus. 

That the motions necessary for these purposes may be readily 
performed, a certain degree of moisture is necessary; but if the 
contents of the stomach be wholly fluid, it is evidently impossible 
that such a process can go on with any degree of precision. The 
fluid can not be so changed as to present a constant and regular 
succession of food, comparatively fresh, to the surface of the sto- 
mach; there will not, therefore, be the same stimulus to excite to 
a continued secretion of gastric fluid, and what is secreted will be 
too easily diffused through the liquid contents of the stomach, to 
make the proper impression on any one part; the same must ne- ; 
cessarily happen to the more digested part in its passage to the 
pylorus; it must be more or less diffused through the other contents 
of the stomach; in short, no part will be duly digested. The 
gastric fluid, being too much diluted for its function, is rather dif- 
fused through the contents of the stomach than neutralized by 
them, hence the appetite is never perfectly allayed, and little 
nourishment afforded. Thus the effects of liquid food tend to 
confirm the view of digestion afforded by the facts, which have 
been laid before the reader. 

When nutritive fluids, however, are mixed with solids, al- 
though of a less nutritious quality, they afford sufficient nourish- 
ment. Strong broth, mixed with bread, or any other solid arti- 
cle of food, is sufficiently nutritious; but it is by no means the 
form, as appears from what has been said, in which nutriment 



80 OF THE TREATMENT 

should be presented to a weak stomach, unless the appetite or ir- 
ritability of the stomach, as sometimes happen, be such that solid 
food can not be taken. The proportion of liquid is too great, if 
there be much broth in the mixture; and if not, it approaches too 
much to the nature of the mucilaginous paste, to permit the di- 
gestive fluids to pervade it with ease. Thus all kinds of broth 
are apt to become sour on a weak stomach, and to cause other 
things to run into fermentation. When liquid nutriment is taken, 
as soups and broths usually are, before other food, it has the ad- 
ditional bad effect of inducing us to eat too much. 

The diet of the dyspeptic should not only be well chosen, but 
simple. Variety is always an inducement to overload the stomach, 
and indeed so intermixed are the feelings produced by the calls 
of hunger, and by the means which please the palate, that, when 
the desire to eat is constantly renewed by a succession of differ- 
ent kinds of agreeable food, it is impossible to judge when we 
have received the proper supply. 

We have reason to believe that by such means an actual in- 
crease of secretion is produced in the digestive organs, and thus 
an artificial appetite, if I may use the expression, excited at the 
expense of subsequent debility; which, although it may not im- 
mediately show itself by symptoms of Indigestion, which also is 
common, at length, in the majority of people, weakens the diges- 
tive powers. 

With respect to stimulating fluids, the operations of the most 
innocent of these seems to be confined to the digestive organs. 
The various aromatic waters, ginger-tea, &c, seem only to be ob- 
jectionable in the same way that other kinds of seasoning are, and 
we shall find, that in certain states of Indigestion they are use- 
ful, in giving temporary tone to the stomach and bowels. 

The most pernicious fluid of this class, it is well known, are 
those which owe their stimulating property to the presence of al- 
cohol. When taken in considerable quantity, they not only 
more, perhaps, than any other stimulants, injure the digestive or- 
gans; but extend their pernicious effects to other parts of the sys- 



OF INDIGESTION. 81 

tern, to which we have reason to believe, they are immediately 
applied by means of the absorbents. 

Like most substances capable of powerfully affecting the ani- 
mal frame, they possess valuable as well as pernicious qualities; 
and, were the former of these less eminent than tbey really are, 
so general is their use in one form or other, and in most people 
the habit which requires their continued use, so fixed, that they 
seldom can be wholly withdrawn, except in very early life, with- 
out doing more harm than good. 

All will agree that alcohol in every shape is unnecessary to 
those who are in health, and have never been accustomed to the 
use of it; and that had no beverage but water ever been known, 
however we might feel the want of a stimulus, in many cases, 
doubtless, the most valuable we possess, a great number of the 
most fatal diseases we are subject to, would have been less fre- 
quent; but these are not the questions before us. Our object is, 
to inquire what is the best for dyspeptics, as we find them in the 
habits of society which prevail in this country. 

As these habits are such, that more or less alcohol is necessary 
to support the usual vigour of the greater number of people, even 
in health, nothing could be more injudicious than wholly to de- 
prive them of this support, when they are already weakened by 
disease, unless it could be shown that even a moderate use of it 
essentially adds to their disease; which in the instance before us, 
we shall find, is by no means the case with respect to all the 
forms in which this stimulus may be taken. 

As dyspeptics then, who have been accustomed to its use, can 
not be deprived of it, and as, under certain circumstances, it is 
even a useful remedy, we are here to inquire how far it is found 
so in Indigestion, and how we can best secure its beneficial and 
avert its evil effects. 

There appears to be an essential difference in the effects of al- 
cohol, such as it exists in fermented liquors, and after it has been 
distilled from them. Both have their inconveniences. So apt is 
the latter to injure the tone of the stomach, that, were it not that 
it is necessary for the solution of certain medicines, frequently 
1! 



■ - 



82 OF THE TREATMENT 

beneficial in Indigestion, we might, without hesitation, banish it 
from the treatment of this disease; with the exception of those 
cases, in which all kinds of fermented liquors, which have not 
been distilled, increase the symptoms, and the patient's habits 
render the use of alcohol in some form indispensable. 

In the fermented liquors which have not been distilled, on the 
other hand, the alcohol is often combined with substances of dif- 
ficult digestion, which are particularly felt by the dyspeptic. This 
is most remarkably the case with malt liquor, of which even the 
weakest kinds often increase the symptoms of Indigestion, and 
the strongest are among the most Indigestible articles of diet. 
The same objection, though in a less degree, exists with respect 
to the other fermented liquors of this country. Of these cider is 
the best, provided the acetous fermentation has not commenced 
in it. Perry usually contains too much mucilage, and some kinds 
are very oppressive to the stomach, apparently from this cause. 
The home-made wines are still more objectionable, being still 
more apt to run into the acetous fermentation. 

The form in which alcohol is most beneficial, and in general 
does least harm, is that of foreign wines. The properties of these 
are various, and different kinds suit different stomachs. The 
astringent property of jiort wine seems to give it a peculiar 
tonic power; and, if it do not constipate, there is, perhaps, no other 
wine so well suited to dyspeptics. It should not be drank till of 
a certain age, the tartar of new port-wine being offensive to the 
stomach. Some dyspeptics find it, as well as the other stronger 
wines, agree better with them, when diluted; and others find the 
lighter wines, particularly claret, better; while with others, all 
the lighter wines, and even port-wine, are acescent. Even in 
these cases, however, the effects of the stronger wines are often 
improved by diluting them. Of this and many other circumstan- 
ces in diet, each individual must judge for himself, as there is no 
rule of general application. 

Many stomachs seem to feel the bad effects of the distilled 
spirits, which, it is said, are added to the stronger wines; for even 
the most objectionable of all the fermented liquors, which have 



OF INDIGESTION. 83 

cot been distilled, appears to be less pernicious than any of those 
which have undergone this process. I have known dyspeptics 
so sensible to the bad effects of the latter, that they have felt an 
increase of debility for several days after drinking a single glass 
of spirits and water. This does not arise from its oppressing the 
stomach, it even for the time assists digestion, and that, if the 
quantity taken be not too great, to a considerable degree, a pro- 
perty indeed which belongs more or less to all fermented liquors, 
though not in the same degree to those which have not been dis- 
tilled. It is this unnatural excitement that seems to do harm. 
It is followed by a corresponding debility; and whatever be the \ 
change induced by distillation, there are no facts, I believe, bet- 
ter ascertained, than that the same quantity of alcohol in the form 
of distilled spirits, although equally diluted, both by its immediate 
operation, gives more temporary assistance to the stomach, and by 
its secondary effects, hurts it more, than in that of any ferment- 
ed liquor which has not been distilled. 

It is thus that many dyspeptics, whose digestion is disordered 
by all kinds of wine, can drink diluted spirits. But it is impos- 
sible by any addition to make their permanent effects similar to 
those of wine. Those addicted to wine seem often to be destroy- 
ed by excess of nutriment. They become full, often ruddy, at 
least for a certain time even robust, and not unfrequently die of 
sanguineous apoplexy. Those addicted to spirits, on the contra- 
ry, generally become pale, often emaciated, and more or less pa- 
ralytic; and although both are subject to debility of stomach, ob- 
structed liver, and dropsical affections, the latter soonest fall into 
those diseases, and in them they make the most rapid progress. 

A very moderate use of wine can hardly be said to be injuri- 
ous; we see those who use it in this way, live as long, and enjoy 
as good health, as those who wholly abstain from it; and to some 
constitutions, independently of the effects of habit, it maybe use- 
ful. I believe neither of these observations apply to distilled 
spirits, although as already hinted, when the stomach has been 
greatly weakened by excess, so that it can not digest any fer- 
mented liquor which has not been distilled, the effects of diluted 



- 



84 OF THE TREATMENT 

spirits are often less injurious, than the total collapse of the sys- 
tem which ensues on wholly withdrawing the accustomed stimu- 
lant. 

The best thing to be done in such cases is, to give no more 
than is necessary, and that in the most diluted form which is 
consistent with the debilitated state of the stomach. The usual 
additions of lemon and sugar which are supposed by many to 
bring the spirit into something like its state previous to distilla- 
tion, according to my experience, only increase the evil, by add- 
ing to the hurtiul stimulant, articles of difficult digestion, without 
at all ameliorating its properties. When it is necessary to use 
distilled spirits, I have found it the best plan to let it be as pure 
as possible, and mix it with nothing but water. I have known 
more than one instance, in which the stomach was even sensible 
to the difference between coloured and colourless brandy. 

Tea and coffee are injurious in another way; they possess a 
narcotic power, which, we have seen, when considerable, is ca- 
pable of producing Indigestion. By many they are regarded as a 
fruitful cause of this disease, but their effects on the whole have, 
perhaps, been over-rated. Green tea, and a very strong infusion 
of black tea or coffee, are injurious to many stomachs. I have 
repeatedly seen severe fits of Indigestion induced by them, al- 
ways characterized by a greater than usual degree of nervous 
affection. To many, however, even these, and to most people, a 
weak infusion of black tea and coffee, seem to be innocent. They 
'"produce no present bad effects, and, where this is the case, I have 
J never been able to perceive any proof of their continued use, 
! doing harm. It is remarkable that their peculiarly refreshing se- 
dative effect is generally, in the first instance, felt even by those 
with whom they most disagree. If drank very hot, they, of 
course, produce the effects of other hot fluids, which we are pre- 
sently to consider. 

It is by no means a fair inference, that what produces very in- 
jurious consequences in some, must do more or less harm in all. 
We frequently see articles of diet, and still more frequently, me- 



OF INDIGESTION. 85 

dicines, which can not be borne by one stomach, perfectly inno- 
cent to another. 

The tendency of tea and coffee to prevent sleep in many peo- 
ple, for even this effect is by no means universal, must be injuri- 
ous as far as the want of sleep is so. It is generally in those in 
whom they produce most of this effect, that their oiher injurious 
effects are most apt to appear. 

There has been some difference of opinion respecting the pro- 
per temperature of the drink of dyspeptics. Some, from the 
present relief obtained from fluids drank very warm, have re- 
commended a high temperature; but the relief thus obtained is, 
like that obtained from distilled spirits, generally compensated 
by subsequent debility. When fluids of the usual temperature of 
the air, are too cold for a weak stomach, which is frequently the 
case, there is no objection to raising them to any degree thai does 
not exceed that of the body; although, when the stomach bears it 
well, fluids of the common temperature seem rather to have a 
tonic effect in Indigestion, A very low temperature is objectiona- 
ble. I have already had occasion to observe that fits of Indiges- 
tion may be induced in weak stomachs by iced fluids. 

I have had occasion, in the preceding observations, to point ouF 
the impropriety of dyspeptics eating too fast or too much, or using 
too liquid a diet; the due repetition of their meals also deserves 
particular attention. 

It is evident from what has been said of the process of diges- 
tion, that a considerable time must elapse after a tolerably lull 
meal, before the more central parts of the food undergo the action 
of the gastric fluid; but, as we are not prompted to eat, till there 
is some uncombined gastric fluid in the stomach, it is evident, 
that it is the intention of nature, that we should abstain till some 
time after all the food already taken has undergone the action of 
this fluid. The accumulating gastric fluid having then no more 
undigested food presented to it, begins so to affect the stomach as 
to occasion the sensation of hunger. The recurrence of this 
sensation, therefore, must be the proper indication, that a due 
time has elapsed since the last meal. 



86 OF THE TREATMENT 

Now this will be different under different circumstances, so 
that it is impossible to lay down any rule of general application; 
but it can never be very soon after an ordinary meal, except where 
the digestion is more rapid than natural, which sometimes hap- 
pens. The patient must be careful to distinguish between a real 
appetite, and a desire to eat what is agreeable, a mistake by 
which we often see the stomach oppressed. On the other hand, 
it is injurious to a weak stomach long to bear the calls of hunger. 

It has appeared to me that, with the generality of dyspeptics, 
to take three moderate meals in the twenty-four hours is the best 
rule. A few, particularly those who are much troubled with a 
sense of depression and sinking, find four meals better. The last 
meal should always be taken a little before bed-time, and should 
never, particularly after the disease has continued for some time, 
consist of animal food. The dyspeptic should eat nothing in the 
intervals of these meals. There is no greater mistake than that 
he should constantly be taking something. This disturbs the na- 
tural process, and entirely prevents the recurrence of appetite, a 
certain degree of which is a wholesome stimulant to the stomach. 
The stomach by this constant eating becoming more and more 
debilitated, and every part by sympathy partaking of the debility, 
the patient wholly misapprehends the cause; and with a view to 
increase his strength, still increases the frequency of his meals, 
till he hardly passes a couple of hours without eating. By such a 
practice, pursued for years, I have repeatedly seen debility of the 
stomach and a morbid irritability of the whole system established. 

It is not, however, to be overlooked, that there are cases of ur- 
gent debility, both in this and other diseases, in which it is for the 
time necessary that the patient should take little and often. Some- 
times the stomach can bear so little food at one time, that were 
the usual intervals of meals observed, due nourishment would not 
be received. But it is not sufficiently attended to, that in such 
states, in proportion as the quantity of nutriment received is les- 
sened, the waste is lessened at the same time. The languor of 
the digestive organs is communicated to other parts of the system, 
and, if the organs of supply are inactive, those of waste are affect- 



OF INDIGESTION: 



ed in a similar way. A clue attention to this fact would often 
prevent the friends of the invalid urging him to take food against 
the appetite, which seldom answers any other purpose but that of 
oppressing the stomach. When it is necessary to eat very often, 
every care should be taken, by recurring, as soon as possible, to 
a better plan of diet, to prevent the habit of very frequent eating, 
being formed. 

Among the other evils of this practice, an artificial want arises, 
and if the patient is not continually taking food, he feels a sense 
of sinking, which persuades him that its constant reception is 
necessary to his existence. Such patients can only be restored 
to regular meals by very gradually increasing the intervals of 
eating. An argument is adduced from the general good con- 
dition of cooks, for eating little and very often, but, it is forgotten 
that a healthy stomach and robust frame will bear many irregu- 
larities, which overwhelm a less healthy or more feeble one. We 
might as well adduce the fact of healthy people being most 
nourished by oily food, as an argument for feeding the dyspeptic 
with butter and fat. No doubt by this constant eating, a great 
deal of food may be taken, and a strong and healthy stomach, 
notwithstanding the way in which it is taken, may digest it; but 
we are here inquiring into the means of best assisting a weak 
stomach. 

I have dwelt the longer on this and other similar points, be- 
cause I have found them essential to the proper treatment of the 
dyspeptic; and, like the process of digestion itself, they have not 
perhaps obtained all the attention they deserve. The study of 
the two subjects, indeed, must go hand in hand; without a correct 
knowledge of the healthy function, it is evidently impossible to 
perceive the principles, on which this part of the treatment of its 
deviations from the healthy state should be founded. 

In the foregoing observations on diet, the attention has been 
chiefly confined to its effects on the stomach, but its influence on 
the bowels of the dyspeptic ought not to be overlooked. Indiges- 
tion, we have seen, is generally attended with languid bowels; 
and, as far as the stomach admits of it, it is proper to make the 



88 OF THE TREATMENT 

diet such, as tends to counteract this state of them. A vegetable 
diet is less astringent than one composed chiefly of animal food, 
and fresh vegetables are more aperient than bread. But this 
must not be carried too far; it is better to take aperient medicines 
than disorder digestion by an improper diet. I have in several 
instances seen advantage from eating household bread, mixed 
with a certain proportion of rice, previously softened by boiling. 
This admixture, contrary to what might be expected, renders the 
bread aperient, but it also, in general, renders it more difficult of 
digestion. It is also for the most part rendered more aperient by 
allowing part of the bran to remain in the flour. 

When there is much irritation of the bowels, mucilaginous 
fluids, in such quantity as does not oppress the stomach, are use- 
ful, even butter and fat are occasionly useful in this way; but, in 
general, any considerable quantity of them so disorders digestion, 
as more than to compensate for their effects in the bowels; and 
not unfrequently the disorder they produce in the secreting power 
is such, that the contents of the bowels become more irritating 
than they were. I have known many dyspeptics, in whom the use 
of butter always had this effect. 

When diarrhoea seems rather to arise from a degree of relaxa- 
tion of the bowels than from the nature of their contents, it is 
proper to use articles of an astringent kind, such as rice seasoned 
, with cinnamon. But it is a great error in the treatment of this 
\ disease, immediately to check diarrhoea, for it generally arises 
from irritating matter, the retention of which would be injurious. 

Upon the whole, however, it is to be observed, that the diet 
best suited to the stomach is generally found best for the bowels 
also; their disorders in this disease, if we except a degree of lan- 
guor, generally arising from the vitiated secretions, which attend 
disorder of the former. 

Of exercise in Indigestion. 

The excercise both of mind and body demands particular at- 
tention in the dyspeptic. 



OP INDIGESTION. 89 

The different kinds of bodily exercise may be arranged under 
three heads; that in which the body is moved by its own powers; 
that in which it is moved by other powers, as in the various 
modes of gestation; and that in which the circulation is promoted 
without moving the body, by friction for example, or merely by 
pressure. 

The dyspeptic may be so weak, that friction is the only kind 
.of exercise which he can bear without fatigue. Wherever the 
strength is much reduced, indeed, although a little of some rough- 
er exercise may be borne, friction is always useful. It is the prin- 
cipal exercise among the higher ranks of some Asiatic nations, and 
it was used both by the Greeks and Romans after they became 
luxurious. It would not be proper in Indigestion to confine the 
friction to the abdomen, when it is the only mode of exercise, 
although in such cases it should be carefully applied to this part. 
To dyspeptics in general, whatever be their other modes of exer- 
cise, friction of the abdomen is always useful. 

Mere pressure is a mode of exercise inferior to friction; but, if 
generally applied to the limbs in an interrupted manner, from the 
valvular structure of their veins, it has a considerable effect in 
promoting the circulation. 

As the total want of exercise is not more pernicious than that ) w 
which occasions fatigue, and no exercise is very beneficial which 
can not be continued for a considerable time, the different kinds 
of gestation, even after the patient has recovered a moderate de- 
gree of strength, are often found preferable to those exercises, in 
which the body is moved by its own powers. 

The gentlest kind of gestation is sailing, which is serviceable 
in almost all cases of debility, and has been found particularly so 
in debility of the stomach and bowels. Next to sailing, the gen- 
tlest exer.cise in common use, is the motion of a carriage; but in 
such climates as our own, unless the patient has been accustomed 
to an open carriage, he must either be confined to a close one, or 
run the risk of taking cold. As substitutes for a carriage, but 
inferior to it, swings and spring-chairs are used. 

None of these modes of exercise is equal to horseback, when 
12 






i, 






90 OF THE TREATMENT 

the patient is strong enough not to be soon fatigued by it. From 
the stimulus given to the alimentary canal by the shaking in rid- 
ing, it appears to be particularly well adapted to Indigestion; and 
every physician has seen instances of this disease, in which it has 
been more beneficial than any other exercise. 

Any rough exercise, however, particularly riding on horseback, 
soon after meals, disturbs the stomach. If the reader will re- 
flect on what has been said of the process of digestion, the cause 
of this will readily appear. We have seen that, in healthy di- 
gestion, no admixture of the new food, with that which may yet 
remain in the stomach from the last meal, and which, if due time 
have been afforded, has already undergone the action of the gas- 
tric fluid, nor indeed of the different parts of the new food, ever 
takes place. We must, therefore, infer, any such admixture is 
unfavourable to this process; and it is evident, from the way in 
which digestion is performed, that, did this happen, some part of 
the food would again be presented to the surface of the stomach, 
after it had undergone the digestive process, and, consequently, a 
corresponding portion of undigested food prevented from approach- 
ing it in due time. 

The mixing of the different parts of the food by any jolting ex- 
ercise will be most apt to take place in the dyspeptic. If we fill 
a closed vessel with such contents as those of the stomach, we 
shall find that but little relative change of place will happen 
among its different parts by shaking the vessel. But if, instead 
of these contents wholly filling the vessel, any space be occupied 
by air, their relative situation will be readily disturbed. Now, 
the stomach always, more or less firmly, embraces its contents; 
but, in Indigestion, air is generally extricated from the food, and 
we have reason to believe, indeed, is often secreted by the surface 
both of the stomach and bowels, and thus room is given fo,r a rea- 
dy change in the relative position of their contents. The dys- 
peptic is often warned against any jolting exercise after meals, 
by the uneasiness it occasions. It is a good general rule, there- 
fore, for him to avoid exercise of all kinds for an hour and a half 
( after eating. This affords an additional reason for not eating too 



OF INDIGESTION. 91 

often. We still find the dictates of nature pointing out what is 
best; for all animals are inclined to repose, and even to sleep, af- 
ter eating. 

Walking, when it can be borne for an hour or two without 
fatigue, is, of all exercises, the best. It is that which nature in- 
tends for us. There is no other accompanied with such a uni- 
form and regular exercise of the muscles and joints; and from 
the valvular structure of the veins of the extremities, it is better 
fitted than any other to promote the circulation, and consequently 
all the functions of the system. It is also the most agreeable 
mode of exercise. Our desire for it when it has been long with- 
held, becomes excessive. 

But in Indigestion, from the peculiar effect on the abdominal 
viscera of riding on horseback, it is generally of service to com- 
bine it with this exercise. I have known some dyspeptics, how- 
ever, to whom horseback was always more or less irksome, when 
it occasioned any degree of shaking. To such, the slowest riding 
alone can be useful, and that only when they are unable to walk 
for a sufficient length of time, and when the weather admits of 
such gentle exercise without a risk of being chilled, to which we 
have seen they are peculiarly liable. 

Those exercises in the open air, in which the bodily exercise 
is combined with a moderate and pleasurable exercise of mind, 
particularly gardening, are well adapted to this disease, provided 
the patient can avoid fatigue, which is not always easily done 
when the mind is occupied. 

A proper exercise of the mind, indeed, is almost of as much 
consequence to the dyspeptic as that of the body. When the 
latter is debilitated and ill at ease, the former is generally lan- 
guid and listless. This state of mind is more or less coun- 
teracted by a due degree of bodily exercise, but the occupation of 
the mind itself is necessary to its cure. 

The maxims by which the exercise of the body is regulated, 
are also applicable to that of the mind. The great rule is, to 
exercise without fatiguing it. Any study which fatigues, is inju- 
rious, and a mind jyholly unoccupied is no less so. When the 



VX OF THE TREATMENT 

debility is considerable, the mind should be occupied by amuse- 
ment alone, and even those amusements which greatly interest 
the feelings, or occasion any considerable effort of mind, are hurt- 
ful. When, on the other hand, the patient has recovered a con- 
siderable degree of strength, a moderate attention even to business 
is serviceable. However varied our occupations, if they tend 
only to present gratification, they soon become insipid. The 
mind must have something in view, some plan of increasing its 
enjoyments, to interest it agreeably for any length of time. There 
are tew things of greater advantage than the conversation of 
friends, who constantly present to the patient the fairest side of 
his future prospects. 

The time of day, at which either the mind or body is exercised, 
is also a matter of importance. Towards evening every kind of 
exertion becomes irksome, and consequently hurtful. In the de- 
bilitated, a degree of fever, or something resembling it, probably 
the consequence of the unavoidable irritations of the day, comes 
on at this time, which is only to be relieved by repose: going ear- 
ly to bed, therefore, is of great consequence to them. It seems 
to be for the same reason that animal food is hurtful at a late 
hour. 

Exposure to the night air appears to be more pernicious than 
we can easily account for.. I am inclined to ascribe its effects to 
the damp which prevails in the early part of the night from the 
condensation of the watery vapour raised during the day, being 
applied to the skin, at a time when, from the state just mentioned, 
its function is most apt to fail. In sultry climates, where the 
evening dews are heavy, the effects of the night air are often fa- 
tal, even to those in health. It is well known, both in the East 
and West Indies, that people are often attacked with agues from 
passing a single night abroad in the woods, where the vapour is 
most confined. Of the baneful effects o\ the night air at Batavia, 
Dr. Lind relates a striking proof in his account of the fevers of 
India: " During the sickly season, a boat belonging to the Med- 
way man-of-war, which attended on shore every night to bring 



OF INDIGESTION. 93 

fresh provisions, was three times successively manned; not one of 
her crews having survived that service." 

The bad effects of the night air, even of this country, to inva- 
lids, I had often remarked, before I began to consider to what it 
might he ascribed. Whatever may be said of the above esp! ma- 
tion, which it would be difficult to verify, — of the fact I have no 
doubt. It may be observed, that the effects experienced from 
the night air by dyspeptics, are similar to those produced on them 
by a damp air from otiier causes. 

It is chief!) to the greater dampness of the air of large towns, I 
believe, that we should ascribe their often disagreeing with dys- 
peptics. Dr. Hutton has shown, that when two portions of air, 
of different temperatures, saturated with water, are mixed, the 
mean temperature will not enable them to hold in solution the 
same quantity of water. I have, from an eminence, o ? served a 
wind, highly charged with moisture, passing over a great extent 
of country, which contained several small towns, and occasion- 
ing a deposition of moisture, wherever it mixed with the air of 
the towns; so that from each of them a streak of mist extended 
in the direction of the wind, the air every where else remaining 
perfectly clear. To the same cause we must ascribe the thick 
fogs of London. They occur when the air is most charged with 
moisture, and in cold weather, when the number of tires being 
greatest, there is the greatest difference of temperature between 
the air of the country and that of the metropolis. A damp air 
feels colder than a dry one of the same temperature, not only be- 
cause it abstracts the heat of our bodies more rapidly, but be- 
cause it tends to debilitate the functions of the nerves of the 
surface. 

Although it is of consequence for the debilitated to go early to) 
bed, there are few things more hurtful than remaining in it too 
long. After the degree of strength, of which the state of the 
system is capable, is restored by sleep, any longer continuance in 
bed, unless the debility be such as to render the mere effort of 
sitting up too much, tends only to relax. Getting up an hour or 
two earlier, often gives a degree of vigour which nothing else can 



I 

94 OF THE TREATMENT 

procure. I have known people whose feet constantly became 
cold and damp if they remained in bed a few hours longer than 
usual. For those who are not much debilitated, and sleep well, 
the best rule is to get out of bed soon after waking in the morning. 
This, at first, may be too early, for the debilitated require more 
sleep than the healthy; but rising early, will gradually prolong 
the sleep on the succeeding night, till the quantity which the pa- 
tient enjoys is equal to his demand for it. 

Lying late is not only hurtful by the relaxation it occasions, 
but also by occupying that time of the day at which exercise is 
most beneficial. 

If the dyspeptic be much debilitated, he should take his first 
meal as soon as he is dressed. He will often find himself hurt, 
and always less benefited by exercise, either of mind or body, 
with the stomach and upper bowels empty, as they necessarily 
are, in the morning. 

When the debility is less, he will often experience benefit from 
J a walk or ride before breakfast. This observation is particularly 
applicable to those in whom Indigestion has produced too great a 
determination of blood to the head, which is, for the time, in- 
creased by the recumbent posture during the night. 

We are most vigorous when the first process of digestion is so 
far advanced, that the vessels which receive the nutriment from 
the intestines are pouring it into the blood; and then it is that a 
free circulation is most useful for mixing the new juices with this 
fluid, and promoting its passage through the lungs, where they 
are perfected into blood. 

Some light and agreeable occupation of the mind, with per- 
fect rest of body, is best for an hour and a half after breakfast. 
From this period to the time of the second meal, which should 
; ^be about the middle hour between breakfast and bed-time, is the 
proper one for all the more powerful exercises either of mind or 
body. The corresponding interval between the second and third 
meal, is better spent in the gentler employments of both; and after 
the last meal, which should be light, the invalid can hardly go to 
bed too soon. 



OF INDIGESTION. 9o 

The objection to going to bed after too full a meal is, that the 
sleep will be disturbed, and consequently less refreshing. Going 
to bed immediately, even after a light meal, in those unaccustom- 
ed to it, will have some degree of this effect, at first, but this in- 
convenience will soon cease. However artificial our habits may 
be, the system is generally soon reconciled to a return to what is 
natural. When four meals in the day are necessary, the interval 
between the first and the last should be divided into three, instead 
of two equal parts. 

Under all circumstances of course, in regulating both diet and 
exercise, attention must be paid to the age and habits of the pa- 
tient. It is seldom proper all at once to attempt the correction 
of the most injurious habits; the change should be made with cau- 
tion and judgment. This is particularly the case with respect to 
the use of fermented liquors and active exercise, because there 
are no means that more essentially influence the constitution; and 
were we suddenly to withdraw the accustomed stimulants, or 
urge to efforts beyond the strength, irreparable injury might be 
done. The more advanced the age, habits are corrected with 
the greater difficulty, both because all habits are strengthened by- 
continuance, and because the less vigorous the constitution is, 
it is the less able to bear the change. 

At advanced periods of life, a change»of habits must not only 
be attempted more cautiously, but it must not be attempted in the 
same degree. It is to be recollected, that in old age repose is more 
necessary, and exertions of every kind less beneficial and more apt 
to be injurious; and that powerful stimulants are less hurtful, both 
because old age requires excitements more, and there is less space 
left for them to produce their pernicious effects. Under all cir- 
cumstances, however, and at all times of life, the principles 
which have been laid down must, I believe, be kept in view. 

Such are the means of preventing the re-application of the 
causes of Indigestion most apt to arise from the disease itself. 
Some others will occur to the mind of every one conversant with 
the disease. Frequent vomiting, diarrhoea, and fits of constipa- 
tion, are among the chief of these, It is almost unnecessary to 
say that they must be corrected as soon as the circumstances of 



.' i- "H 1 



96 OF THE TREATMENT 

the case admit of it. The means proper for these purposes will 
appear in considering what may be called the medicinal part of 
the treatment. 

Of the Medicinal Treatment in the first stage of 
Indigestion. 

It appears, from what has heen said of the nature of the first 
stage ot Indigestion, that it arises from the debility of the muscu- 
lar fibres and nervous influence of the stomach and bowels. 
While we are, by a proper regulation of diet and exercise, en- 
deavouring to prevent every cause which may increase their de- 
bility, it is necessary, by the aids which medicine affords, to en- 
deavour more directly_tojrstore their vigour. 

The medicinal treatment of this stage may be divided into that 
indicated while the disease is confined to the stomach and bowels, 
and that which becomes necessary in consequence of its having 
spread to other parts. 

But, besides the means which alone deserve the name of cu- 
rative, others to be regarded as preparatory, must occasionally be 
employed. To give the curative plan the best chance of success, 
it is not only necessary to remove the remote causes and prevent 
their re-a*pplication; but, as far as we can, to remove the more 
immediate effects of these causes, and thus bring the digestive 
organs into the circumstances most favourable to the operation of 
that plan. 

Of the Preparative Means. 

When we are consulted by those labouring under Indigestion, 
we generally find the stomach and bowels loaded. It is neces- 
sary in the first place, to relieve them from some part of this load, 
and, as far as we can, to correct the properties of that which re- 
mains. On this account we frequently find it a jvisable to com- 
mence the treatment by an emetic, followed by some mild aperi- 
ent. It should be our endeavour, by an attention to the proper 



OP INDIGESTION. 97 

rules of diet, to prevent the necessity of repeating the former of 
these; and the latter, we shall find, only makes part of the gene- 
ral plan, as far as it is necessary for the regular and free action 
of the bowels. 

An emetic, in the early stages of the disease, seems sometimes 
beneficial by the excitement, as well as the evacuation, it occa- 
sions. Its frequent repetition, however, is injurious. Frequent 
vomiting, we have seen, ranked among the causes of the disease; 
yet the temporary relief, obtained by emetics, not only often in- 
duces the patient to repeat them, but has persuaded some physi- 
cians, that the cure of the disease may be attempted by them 
alone. 

If the first emetic, however, does not remove it, as sometimes 
happens when it is slight, and of recent occurrence, rather de- 
serving the name of disordered stomach than the disease we are 
considering, its repetition generally does more harm than good. 
If emetics are repeated at all, it should only be for the purpose of 
removing urgent symptoms. Their continued use not only occa- 
sions a great degree of morbid excitement, but inverts the natu- 
ral action of the stomach, and frequently of the first intestine 
also, and consequently tends to debilitate both, and break the ha- 
bit of their natural functions. 

When it appears that offensive matter still exists in the stomach 
and bowels, after the operation of the emetic and aperient, which 
may be known by a sense of oppression and distention of these 
cavities, and by eructation of wind and ill-digested food, or of 
an acid matter, which is sometimes so acrid as almost to excori- 
ate the fauces, we must, by gentle stimulants, particularly the 
distilled waters occasionally mixed with a small proportion of 
some aromatic tincture, endeavour to excite them to a better se- 
cretion; and at the same time, by the use of correctives, more 
directly to alter the morbid properties of their contents. 

When the eructations are acid, the alkalis, magnesia, lime- 
water, and prepared chalk, are the best correctives. If the fore- 
going symptoms are attended with much debility, a cold surface, 

and sense of sinking, carbonate of ammonia is the best. When 
13 



98 OF THE TREATMENT 

the bowels are too languid, magnesia, which forms an ape- 
rient salt, with the acid of the first passages, may be used; and 
when diarrhoea prevails, lime-water, and the prepared chalk, 
which are astringents. In this case also, combining the chalk 
with some mucilaginous substance, which defends the surface of 
the stomach and bowels, as in the mistura cretae, is generally of 
use. When none of the latter symptoms prevail, the fixed alka- 
lis, particularly soda, from its greater power, is the best antacid. 

Although morbid acidity may be lessened, it can not be wholly 
prevented by a diet consisting chiefly of animal food; and I have 
repeatedly had occasion to observe, that when a person is wholly 
confined to animal food, the contents of the stomach and the 
breath become very acid as soon as he begins to feel disgusted 
with it. 

As the pains, which arise from irritating matter in the stomach 
and bowels, proceed either directly from irritation of their sur- 
face, or from spasms excited by the irritation, they are generally 
allayed by the means just pointed out. In the latter case, which 
is distinguished by the severity and intermitting nature of the pain, 
unaccompanied by the symptoms which indicate inflammation, 
the aromatic tinctures may occasionally be used in larger doses 
than would be proper in their habitual employment. 

If the foregoing means fail, an opiate must be given, care being 
taken by the subsequent exhibition of an aperient, to counteract 
its constipating tendency. The exhibition of the aperient with 
the opiate tends to prevent the effect of the latter. 

Spasm of a more permanent nature seems sometimes to attend 
and oppose a powerful obstacle to the action of the bowels. In 
such cases the combination of an opiate with the aperient, seems 
often to promote its operation. The repetition of the opiate, un- 
der such circumstances, however, requires great circumspection. 
It may, by counteracting the peristaltic motion of the intestines, 
prove a more obstinate cause of constipation than the spasm 
which it removes. 

When the diarrhoea, excited by the irritating contents of the 
bowels, continues after we have reason to believe that its cause 



OF INDIGESTION. 99 

has been expelled, mucilage of acacia, with small closes of opium, 
or if these alone do not succeed, combined with astringents, are 
the proper means. 

When vomiting is obstinate, it is often allayed by the saline 
draught taken in a state of effervescence, or a mixture of sulphu- 
ric acid, conserve of roses, and peppermint-water, carefully strain- 
ed. If these fail, the most effectual means, according to my ex- 
perience, is a pill, composed of opium and camphor, and blister- 
ing the region of the stomach.* 

Such are the means, by a judicious employment of which the 
stomach and bowels are brought, as nearly as their debilitated 
functions admit of, into the natural state; the more nearly this can 
be done, the better is the chance of relief from the means we are 
now to consider, namely, those which more directly tend to re- 
store tone to the stomach and bowels. 

Of the Treatment when the Disease is confined to the 
Stomach and Bowels. 

We have seen that, although the causes of Indigestion seem, 
some to act on the muscular fibres of the stomach, and some on 
its nerves, yet these powers are so connected in their functions, 
that whatever debilitates the one, in a greater or less degree, ne- 
cessarily affects the other. We shall find that a similar observa- 
tion applies to the means of relief. Whatever tends to restore a 
healthy nervous power to the stomach, tends to form the food 
into that substance which is best fitted to excite the muscular fi- 
bres of this organ; and whatever excites the natural action of these 
fibres, tends to relieve the nerves from their load, and in the most 

* When, in the second stage of Indigestion, along with the vomiting- 
there is considerable tenderness on pressure in the epigastrium, the means 
which take off the inflammatory action, particularly loss of blood from the 
part, with subsequent blistering, are the most effectual 

In the affection of the stomach, called the water-brash, there is a frequent 
rejection, rather resembling eructation than vomiting, of a watery fluid 
from the stomach. I cannot help agreeing in opinion with Dr. Cullen, that 
this is a peculiar affection of the stomach, not depending on the state of 
that organ which produces the disease we are considering. It is not ne- 
cessarily accompanied by the symptoms of Indigestion. 



100 OF THE TREATMENT 

favourable way, to bring into contact with their extremities the 
food on which, through the intervention of the gastric fluid, their 
powers are to be exerted. 

Although some of the remedies seem to operate more in the 
one of these ways than in the other, as I wish to avoid nice dis- 
tinctions, it will be better to include the whole under one head, 
in an inquiry respecting the use of tonic remedies in this disease; 
and I shall attempt no other division than the simple one of the 
means which act directly on the stomach and bowels, and those 
which influence them through other parts. 

The former may be divided into two classes, those which tend 
to excite, for the time, the particular function of these organs, or 
allay the irritation of their nerves; and those which seem to act 
less by any immediate effect, than by bestowing on them some 
degree of permanent vigour. 

The medicines of one class have been termed stimulants and 
anodynes. The most powerful of the other consist of bitters, as- 
tringents, and those medicines which tend to support a due ac- 
tivity of the bowels. 

I have already had occasion to observe, that simple distilled 
spirits, and still more the aromatic tinctures, tend for the time to 
promote the action of the stomach; and to warn against too free 
a use of them; because the increased vigour thus procured, espe» 
cially if they have been feequently repeated, is generally succeed- 
ed by corresponding debility, By very small doses of such 
medicines, however, particularly when combined with those 
whose effects are more permanent, advantage on the whole arises. 
We find that bitters and astringents not only produced their good 
effects more speedily, but, for the most part, more permanently 
also, if combined with small doses of those medicines, which are 
more purely stimulant; and, indeed, the action of the latter seems 
often necessary to enable the stomach to bear the former without 
oppression. 

Thus it has become an universal practice to combine a small 
quantity of distilled spirits and aromatics, with other stomachic 



OP INDIGESTION. 



101 



medicines. The quantity of distilled spirits in such mixtures 
should always be small, a twelfth, at most an eighth, of the whole. 
The choice of the aromatic is of less consequence; the properties 
of all are similar. Some suit the stomach and the taste of indi- 
viduals better than others. There is, upon the whole, however, 
some difference in their properties. Ginger may be used when 
cardamoms would heat too much, and cardamoms will relieve 
flatulence and spasmodic pains, when ginger would fail. 

Similar in their operation to this class of medicines are, am- 
monia and its carbonate, which have not, perhaps, obtained all 
the attention they deserve in this disease. They are more apt to 
heat than aromatics, and, in the same proportion, more beneficial 
in that languor and coldness, which are often such prominent fea- 
tures of Indigestion. Their greater tendency to heat seems to 
arise from their acting as a more general stimulant. They are 
more apt to strengthen and quicken the pulse, and, probably, act 
on the sanguiferous system after they are taken up by the absorb- 
ents; I have found them decidedly serviceable when aromatics 
had failed. They are best adapted to those cases where a con- 
tinuance of the disease has produced much debility, and conse- 
quent languid circulation, without much tenderness of the epigas- 
trium, or hard pulse, or any sensation of burning in the hands or 
feet at night. 

Camphor possesses some of the properties of ammonia in a 
slighter degree. Its sedative property renders the mistura cam- 
phorae a good vehicle for other medicines. 

Among the means of temporary relief in Indigestion, very 
warm water holds a higher place perhaps than is generally sup- 
posed. To its frequent use we have seen there are the same ob- 
jections as to other powerful stimulants. It deserves mentioning, 
although it is difficult to explan it, that a considerable degree of 
heat, I mean nearly as much as the patient can bear without 
complaint, applied externally to the region of the stomach, is more 
effectual, provided it be continued for a sufficient length of time, 
in relieving that kind of pain of the stomach which most frequent- 
ly attends Indigestion, than any application of heat we can make 



102 OF THE TREATMENT 

internally. It is also frequently relieved by heat applied to the 
feet. 

Opium belongs to the head of remedies employed for tempo- 
rary relief. Large doses of this medicine have no place in the 
treatment of Indigestion, except for the purpose of relieving se- 
vere pain. The other symptoms are increased by them. Very 
small doses, however, two or three minurns of tincture of opium 
for example, repeated two or three times a day, often prove highly 
serviceable in allaying morbid irritation, and their constipating 
effect is generally easily counteracted. They sometimes indeed 
have very little of this effect. . 

I have found the pulvis ipecacuanhas compositus the most 
beneficial form in which small doses of opium can be given in 
this disease. From two to four grains of this preparation, given 
every six or eight hours, appear to have a peculiar effect in al- 
laying the irritations attending Indigestion, which probably arises 
from its action on the skin. It appears to be best adapted to 
those cases in which that combination of languor and restlessness, 
often so remarkable in this disease, prevails. It is better from 
time to time to discontinue and renew its use, than to exhibit it 
for a great length of time, without interruption; which, even 
when the dose is very small, is apt to occasion confusion or other 
uneasiness of the head. 

The effect of opiates in Indigestion explains an observation 
sometimes made by dyspeptics, that they find their dinner digest- 
ed with less flatulence and acidity, when they go to sleep after 
it. The composure produced by sleep, in some degree, answers 
the purpose of the opiate. In many dyspeptics a small dose of 
opium, taken after dinner, gives more relief, and, for the time, 
more effectually promotes digestion, than any other means. It is 
almost unnecessary to add, that the habit of having recourse to it 
for this purpose would be very objectionable. It is probably on 
account of its anodyne quality, that lettuce, as I have had occa- 
sion to observe above, appears to be less indigestible than other 
raw vegetables. 

In considering the causes of Indigestion, we have seen how 



OF INDIGESTION. 103 

readily the disease is increased by every tiling which occasions 
morbid irritation of the nerves of the stomach. It is, in a great de- 
gree, in this way that the undigested contents of a weak stomach 
aggravate the symptoms. By lessening the sensibility of the 
nerves, and thus allaying that irritation, an opiate seems to check 
the progress of Indigestion, as well as to render us less sensible 
to the irritating matter already formed. 

The medicines called nervous are also often useful in allaying 
irritation of the nerves in Indigestion, especially when it chiefly 
affects parts at a distance from the stomach. Myrrh, camphor, 
castor, and valerian, I have found most beneficial, except when 
the disease inclines to hysteria, and then a combination of some 
of these, and asafoetida, is a means of temporary relief, second, 
perhaps, to none but ether, which approaches too nearly to the 
nature of distilled spirits, to admit of its free and frequent em- 
ployment. This class of medicines, and particularly the combi- 
nation just mentioned, that especially of asafoetida and castor, 
seldom fail to give relief in palpitation arising from Indigestion, 
if no inflammatory disposition have supervened. It also, in gen- 
eral, gives more or less temporary relief to the dyspnoea, which 
we have found sometimes so obstinate a symptom of this disease. 
Of the various medicines of this class, however, those best suited 
to some cases are not always most effectual in others; and when 
such as are on the whole most successful fail, others often suc- 
ceed. 

But it is of much less consequence to give relief in fits of In- 
digestion than to prevent their recurrence. We are now to in- 
quire how far medicine can assist the due regulation of diet and 
exercise in effecting this object. 

The small doses of opium which I have just had occasion to 
mention, are calculated to effect more than temporary relief in 
Indigestion. I have found them, or rather still smaller doses, 
one or two grains, for example, of the pulvis ipecacuanhas com- 
posite, of essential use, combined with the medicines we are 
about to consider. 

It has already been observed, that of the tonics whose effect is 



104 OF THE TREATMENT 

most permanent, bitters and astringents are those on which we 
chiefly rely, and that their effect is increased by combining them 
with small doses of some of the stimulants we have been consid- 
ering. 

Bitters have been long known to possess a power of invigorat- 
ing the digestive organs. There is a great variety of them, but I 
believe they may all be divided into simple bitters, and those 
which at the same time possess a stimulating quality. Of those 
in common use, camomile, bitter orange-peel, and wormwood, 
seem to be the most free from this quality*. Columba possesses 
it in a greater degree than gentian and cascarilla, and the Peru- 
vian bark in a greater degree than any other. I speak not at 
present of the astringency of the last, which renders it a medicine 
of different properties. It is particularly to be observed that the 
stimulant property of bitters, although less immediately powerful, 
is of a more permanent nature than that of the stimulants which 
we have been considering; and the latter may often be used for 
the purpose of occasional relief, when the inflammatory tendency 
is too great to admit of the more permanent stimulant. 

All the foregoing bitters, if we except the bark, which is often 
oppressive to the stomach, are well suited to the first stage of In- 
digestion; but in proportion as the second stage approaches, we 
find the less stimulating bitters answer better; and in this stage, 
even the gentian, which, of those that deserve the name of stim- 
ulating, possesses, perhaps, the least of this property, is often too 
heating, and the bark in general can not be borne, even for a few 
days; while in the earliest periods of the disease, when it super- 
venes on debilitated states of the constitution, and the stomach 
still retains considerable comparative vigour, a cold infusion of 
the bark is often the most beneficial of all bitters. It has by 
many been banished from the treatment of Indigestion, but this, 

* By stimulating quality of bitters, I mean the power by which some of 
them increase the force of the circulation, and consequently are rendered 
improper where the inflammatory diathesis prevails. It seems not to be 
generally known, that this property bears little relation to the quantity of 
essential oil which they contain. 



OF INDIGESTION. 105 

I believe, has arisen from its having been employed indiscrimi- 
nately in all cases and periods of the disease. 

It is remarkable that certain stomachs can not bear any spe- 
cies of bitter. I have known some who constantly suffer from 
even a few spoonfuls of camomile tea; so that in them we are 
wholly precluded from the use of this class of medicines. 

Many object to the long continued use of bitters and aroma- 
tics. There are strong objections to the long-continued use of 
every medicine If it is one of great power, it exhausts the 
strength; if not, it seems to become almost wholly inert. When 
the disease is obstinate, it is better, after a certain degree of re- 
lief is obtained, to discontinue such medicines, and, sooner or 
later, recur to them, as the symptoms may require. 

I believe, however, the apprehensions from their long-continu- 
ed use have chiefly arisen from their effects in gouty cases. It 
prevents the regular returns of this disease, as has been proved 
by the effects of what was called the Portland Powder, and some 
other specifics: but it appears, I think, from the facts stated in 
the last chapter, that the bad effects which ensue should rather 
be ascribed to the prevention of the regular gout, than any direct 
operation of the medicine. The same effects follow, when the 
return of regular fits is prevented merely by applications to the 
joints, which we know, independently of this consequence, could 
have no serious effect. 

Astringents are less generally adapted to cases of Indigestion 
than bitters, on account of their tendency to increase the inactivity 
of the bowels, which so generally prevails in this disease. Some 
of them, however, are medicines of such value, that we often find 
it advisable to employ them, although at the expense of correct- 
ing this effect. Nor are they in all cases equally apt to produce it 

All vegetable astringents seem to have more or less tonic effect 

on the stomach, as well as on other parts of the system; and to 

this we must, in some degree, ascribe the good effects of the bark 

in the cases above pointed out; but the mineral kingdom affords 

the most beneficial medicines of this description. Of these, iron 

deserves the first place. In chlorotic Indigestion, combined with 
14 



106 OF THE TREATMENT 

stimulants, it is the most powerful medicine we possess, because 
it is the most powerful in removing the obstruction whence the 
Indigestion by sympathy arises, so that in this case it belongs 
rather to the class of remedies which we are next to consider; 
but there are few cases of Indigestion in which it is not found 
more or less useful at an early period, if no tendency to the second 
stage of the disease has shown itself. Its good effects are in- 
creased by combining it with bitters and aromatics; and, in 
idiopathic Indigestion, the carbonate has appeared to me its best 
preparation, provided it can be taken in rather large doses, with- 
out oppressing the stomach. 

Next to iron, the sulphuric acid seems to be the best stomachic 
astringent, and it may be used in later stages of the disease than 
iron. It is particularly serviceable in those cases, where sweat- 
ing, which is not unusual, is too easily induced by exercise; for 
much tendency to sweating indicates relaxation, not vigour of the 
skin. It appears from the experiments relating to the circum- 
stances which influence the state of the urine, above referred to, 
that the saline matter, secreted by the skin, is not so certainly 
thrown off, even by profuse sweating, as by a free insensible per- 
spiration. 

In the opinion of many, the sulphate of zinc, given in very small 
doses, also holds a distinguished place among the astringents 
suited to Indigestion. It may be given at later periods than iron, 
but it requires caution; and if its good effects do not soon appear, 
should be laid aside. It is one of those powerful agents, which 
must always be employed with some degree of suspicion. 

Other medicines beside bitters and astringents, seem to act in 
a similar way on the alimentary canal. All the mineral acids 
possess more or less of a tonic power. The white oxide of bis- 
muth has lately been much celebrated. It seems best adapted 
to those cases in which there is frequent recurrence of pain re- 
ferred to the stomach. 

To enumerate all the medicines which have been employed 
with a view to restore vigour to the stomach and bowels would be . 
a difficult task, and not a very useful one; for few, with the excep- 



OP INDIGESTION. 107 

tion of the foregoing, possess much power. The acrid vegetables, 
particularly horse radish and mustard-seed, are indicated in the 
same cases in which ammonia and aromatics are most beneficial. 
Their infusion often forms a good vehicle for ammonia and its 
carbonate. 

Sarsaparilla appears to me to hold a much higher place among 
the remedies of this disease than is generally supposed, but it is 
not to its early stages that it is best suited, and from its mucila- 
ginous property, it is apt to oppress the stomach. It is in pro- 
tracted cases, where general languor of the secreting surfaces has 
become permanent, and the stomach is consequently in some 
degree relieved, that it is most useful. I shall have occasion to 
make some observations upon it in speaking of such cases. 

It has become common to employ mercury in some form or 
other in all cases of Indigestion; but, I believe its use is always 
injurious in the period of the disease we are now considering; 
that is, while the derangement is confined to the alimentary canal, j 
I shall have occasion to treat fully of what appears to me the 
proper use of this medicine in the other stages of the disease. 
Instances have frequently occurred, in which the disease seemed 
to be confirmed by its unnecessary and improper employment. 
I believe we may say, without hesitation, that it is never to be 
used in any stage for the mere purposes of an aperient. 

The proper use of aperients is a subject of great importance at 
all periods, and in all states of Indigestion. In the period under 
consideration, their object is merely to support a regular action of 
the bowels, which as the secretions of the whole canal are inclin- 
ed to fail, and the stomach and upper bowels do not discharge 
their contents so readily as they ought to do, should be rather 
freer than in health. It often has an excellent effect to combine 
bitters with gentle aperients in the early stages of the disease. 
Epsom salts are frequently employed in this way with great ad- , 
vantage. If they are too cold, or occasion too watery a discharge, 
small doses of sulphate of potash and rhubarb often answer bet- 
ter. 

Different aperients suit different constitutions. I have found 



108 OF THE TREATMENT 

none employed merely for the purpose of supporting a regular ac- 
tion of the bowels, so generally, as pills composed of ipecacuanha, 
compound extract of colocynth, and soap, with the addition of a 
little gamboge, when they are not sufficiently active, occasionally 
taken at bed-time. In many senna has appeared to me a medi- 
cine of great value. It seems more directly to promote digestion, 
at the same time that it excites the bowels; a property also of 
the pills just mentioned. 

With respect to those remedies which act on other parts, and 
only by sympathy influence the alimentary canal, the most pow- 
erful and, indeed, the only ones which appear to have much effect, 
are such as make their impression on the uterus and the skin, 
I have already had occasion to mention one of the most powerful 
of the means tending to restore the functions of the uterus. All 
this class of course are beneficial in Indigestion, as far as it de- 
pends on a failure of those functions. With respect to the means 
which make their impression on the skin, the cold bath, where 
there is considerable general vigour, and the warm salt bath in 
almost all cases, the shower bath, particularly where there is too 
much determination of the blood to the head, and spunging the 
body with salt water, or water and vinegar, especially when this 
practice is followed by friction of some continuance, often aid 
other means, and sometimes appear to be powerful remedies. 
Among these means might also be ranked blistering the epigas- 
tric region, were not so severe a remedy hardly allowable in the 
earlier periods of the disease, where gentler means generally 
succeed. Covering the epigastric region with stimulating and 
anodyne plasters is sometimes of use, 

The gastric fluid of other animals has been proposed as a re- 
medy in Indigestion. If the view which has been taken of this 
disease be correct, it could answer no other purpose but that of 
temporary relief. I have known the inspissated bile of the ox 
used as a cathartic in Indigestion with good effect. It appears to 
deserve attention, particularly in the state of the disease we are 
now to consider. 



OP INDIGESTION. 109 

Of the Treatment when the Disease has spread fur- 
ther than the Stomach and Bowels. 

It is observed in tbe first chapter, that, sooner or later after 
the first symptoms of this disease have shown themselves, the 
alvine discharge begins to deviate from the healthy state, in dif- 
ferent cases, and sometimes in the same case at different times, 
assuming various appearances. The treatment then becomes 
more complicated. 

When the alvine discharge assumes an unnatural colour, we 
may be assured that the disease has spread further than the ali- 
mentary canal. The secreting power of the liver, and, probably 
of the pancreas, partakes of it. As these organs pour their se- 
cretions into the first intestine, the state of which seems greatly 
to influence the symptoms of the different stages of Indigestion 
they immediately affect the greater part of the canal, and, by 
sympathy greatly influence the state of the stomach. From the 
size, structure, and position of the duodenum, it is evidently the 
intention of nature to detain its contents for some time, that they 
may be intimately mixed with those secretions; and we have rea- 
son to believe, that the process which takes place in this intes- 
tine, is essential to the due formation of chyle. The beneficial 
effect of purgatives in Indigestion seems greatly to depend on 
their assisting its motions. It appears, from the enumeration of 
the symptoms, that they are much influenced by the state of the 
ducfdenum; and 1 have, from several cases, had reason to believe, 
that the peculiarly beneficial effects which I have witnessed from 
the senna in Indigestion, arise from its being well fitted to pro- 
mote the action of this intestine. It has appeared more effectu- 
ally to remove the fulness of the right hypochondrium, when it 
depends on morbid distention of the duodenum, than any other 
medicine equally mild in its operation. 

The change in the appearance of the alvine discharge, we 
have seen, occurs at various periods of the disease; in some cases, 
almost as soon as the symptoms of Indigestion begin to attract 



110 OF THE TREATMENT 

notice; so that it is difficult to say, except from considering the 
nature of the remote causes, where the disease originated. It 
is more common, however, tor it to take place after various symp- 
toms of disordered digestion have lasted for some weeks, and the 
slighter symptoms, we have seen, may continue for years without 
any material alteration in the appearance of this discharge. 

Of the particular state of the pancreatic fluid, we have no 
means of judging. The alvine discharge, it appears from what 
was said above, generally owes its colour to the bile. By the 
degree of colour, therefore, we may judge of the quantity of bile 
poured into the intestines, and by its hue, of the state of this fluid. 
An admixture of blood, when it flows from a high part of the ca- 
nal, so that it is mixed with the other contents, and has had time 
to assume a dark colour, before it is discharged, sometimes gives 
to the discharge an appearance similar to that given by certain 
states of the bile. They may be distinguished, however, by dilu- 
tion with water; if the change of colour arise from bile, a green- 
ish or yellowish shade will be produced; if from blood, a dark 
brown one. 

When the change in the alvine discharge takes place, then, we 
are assured, that in addition to the original disease, we have to 
contend with derangement in the function of the liver. The case 
is now not only more complicated, but more difficult of cure: the 
diseased action of parts which sympathize, while there is no de- 
gree of structural derangement tending to confirm each other. 

The principle of the treatment is to combine with the means, 
which tend to restore vigour to the alimentary canal, which we 
have just been considering, those which correct the morbid state 
of the liver. It is generally admitted that we possess no medicine 
of equal power with mercury in correcting the morbid states of 
this organ, but it unfortunately happens that its continued use is 
generally injurious to other organs, and particularly to the stomach 
and bowels; and the chief object to be kept in view in its employ- 
ment in this stage of Indigestion is, so to manage its exhibition, 
that it shall produce the desired effect on the liver, with as little 
injury as possible to other parts of the system. 



OP INDIGESTION. Ill 

The first observation which presents itself on the employment 
of mercury at this period of the disease is, that it is not to be so 
given as to be received into the circulating system. Mercury, 
when thus introduced, has the property of more or less exciting 
all the secreting surfaces, but their excitement is supported by it 
at great expense to the constitution, and when long continued, 
seldom fails to impair its powers. No practice can be worse than 
that which unnecessarily risks this effect. In the first stage of 
Indigestion, there is no occasion to change by such powerful means 
the state of the general habit to which the diseased action has but 
imperfectly extended, and in which it is still so purely sympa- 
thetic, that it immediately disappears as soon as the disease of 
the central parts is removed; and experience has amply proved, 
that the deranged action of the liver can, in consequence of the 
sympathy which exists between this organ and the alimentary 
canal, be corrected by the local effect alone of the mercury on 
the latter. 

Another observation of importance respecting the use of mer- 
cury at this period is, that its long-continued use is seldom neces- 
sary. The practice of giving it every second day, or even daily, 
and almost indiscriminately, in cases of Indigestion for a consid- 
erable length of time without attending to the state of the alvine 
discharge, although its reception into the system be prevented by 
the regular use of purgatives, is, as far as I can judge, in opposi- 
tion to every thing which we know of the nature of the disease, 
and the effects of this medicine. 

What are the effects which we expect from the use of mercury, 
in the first stage of Indigestion after a healthy secretion of bile is 
restored, which is often effected by two or three doses, sometimes 
by one? It is true that a recurrence to it is generally necessary, 
but in the first instance we should wait till we see whether this 
necessity will be indicated by a return of the morbid state of the 
bile. The effect of its first exhibition is more or less permanent 
in different cases, and the most favourable cases, when we have 
obtained a healthy flow of bile, yield to the other means we have 
been considering. 



112 OF THE TREATMENT 

In the more obstinate cases, indeed, where the disordered state 
of the liver constantly recurs at short intervals, it is better for a 
certain time to give a moderate dose at stated intervals, by which 
the alimentary canal will suffer less, as a smaller dose is requir- 
ed for the prevention of this state, than for its removal. But even 
in these cases, this practice should not be long pursued, without 
trying from time to time how far the powers of the constitution 
are sufficient without its aid. By these means we ascertain the 
extent to which it is necessary to carry the use of this medicine. 

The form in which it should be exhibited is also a point of great 
importance. It ought never, we may safely affirm, in the case 
before us, to be used externally; for we have no reason to believe, 
that its action on the skin can materially affect the liver by- sym- 
pathy; and we often find that, when exhibited in this way, it pro- 
duces little effect on that organ, tilf the state of the gums shows its 
presence in the constitution, which I have already had occasion 
to observe, is at this period unnecessary. 

All that is here wanted is something that may speedily correct 
the disordered function of the liver. To produce this effect 
quickly, without being more generally applied to the system than 
is uecessary, mercury must be given internally. The sympathetic 
effect on the liver, during its passage through the alimentary ca- 
nal, we have seen, is sufficient for the purpose, 

There are two forms in which it is usually given, calomel and 
blue pill. The former being the most aperient, it is a good gen- 
eral rule to give it when the bowels are most languid, and the 
blue pill when they are more easily excited. But this is not the 
only property inwhich these preparations differ. The blue pill 
is generally most oppressive to the stomach; the calomel most ir- 
ritating to the bowels; although in some cases, I have seen the 
former, in very delicate subjects, from its being less cathartic, 
and consequently, for a longer time, hanging about the bowels, if 
I may use the expression, more irritating than calomel. 

For the same reason, small doses of calomel, a quarter, or half 
a grain, are often more irritating than t wo or three grains, which 
more quickly pass off; and the irritation of the bowels is most effect- 



OF INDIGESTION. 113 

ually prevented by taking an opening draught some hours after 
the calomel. With most people, this is not necessary when the 
blue pill is taken, its continuance in the bowels generally giving 
less uneasiness. 

From these properties of the two preparations, the reader will 
readily perceive the circumstances which should influence our 
choice of them. In the most recent cases, calomel taken at night, 
and carried off by an aperient draught in the morning, generally 
answers best. Here we want only the most transitory action of 
the medicine. 

On the other hand, when the disease has lasted longer, or the 
first few doses of calomel have failed to produce a permanent 
flow of healthy bile, we feel the necessity of employing a prepa- 
ration which may remain longer in the alimentary canal with 
Jess irritation than calomel would produce were it retained there. 

Hence the great success which often attends giving four or five 
grains of the blue pill every second or third night, as recommend- 
ed by Mr. Abernethy, particularly in those cases where the affec- 
tion of the liver has supervened early, and where, consequently, it 
is the principal cause which supports and aggravates the disease. 
This observation, it is evident, applies with still greater force, 
when it is the original disease, and the alimentary canal suffers 
only by sympathy and the irritation of the vitiated secretion of 
the liver. It is always to be recollected, however, that in Indi- 
gestion it is an unhealthy secretion of bile alone which renders 
mercury necessary in the first stage, that the time in which it 
produces the necessary effect is different in different cases, and 
that all that is taken after this is injurious. 

In some, the blue piil is so oppressive, that I have seen several 
who could not take it even in much smaller doses.* To them it 

* It is remarkable that the blue pill is so offensive to some constitutions, 
that I have seen several instances, in which it disordered the secretion of 
bile, even when it was healthy at the time of its exhibition; and in such cases, 
as far as I have observed, the disordered state of the bile continues as long 
as it is used. This effect is similar to that which we sometimes observe 
from repeated doses of calomel in children. 

15 



114 OF THE TREATMENT 

is necessary to give small doses of calomel, and if it irritates, to 
combine it with anodynes. 

It also deserves particular attention in the choice of these 
means, that the most beneficial use of calomel necessarily occa- 
sions brisk purging, on which the benefit derived from it often 
greatly depends; while, by its peculiar effect on the first passages, 
it excites a better action of the liver; by its purgative effect, as 
well as by that of the draught which its exhibition renders ex- 
pedient, it tends further to emulge the gall-ducts, and relieve the 
distended state of the liver. 

Its operation then is most wanted where this distention is great- 
est, which may be known, we have seen, by the state of the right 
bypochondrium, and will be least injurious where the strength is 
most able to bear so considerable a call upon it. When there is 
little distention of the liver, and the strength is much reduced, 
the operation of the blue pill, provided it agrees tolerably well 
with the stomach, is preferable. The relief obtained from it may 
be less speedy, but it. will be obtained at less expense to the con- 
stitution. Instances frequently occur of the bad effects of not at- 
tending to this distinction. What is only a salutary evacuation in 
one case, is an overpowering cause of debility in another. 

Where the symptoms are rather obstinate than severe, and 
where they yield readily, but continually show a tendency to re- 
turn, covering the parts, to which the tenderness and fulness have 
extended, with a warm mercurial plaster, often, in the former in- 
stances, tends to remove the disease; and in the latter, to prevent 
its recurrence. I have known such a plaster worn for months, 
and even j'ears, the symptoms constantly recurring when it was 
laid aside. 

When mercury occasions much irritation of the bowels, its 
continued use brings on a degree of the dysentery. Calomel, we 
have seen, is most irritating; it is, therefore, most apt to produce 
this effect. The patient is tormented with griping and tenesmus, 
and at length passes little more than mucus, often mixed with a 
small quantity of blood. If in such cases, we increase the dose 
of mercury, in hopes of freer evacuations, we only increase the 



OP INDIGESTION. 115 

evil. Discontinuing its use for a little is the best remedy; and 
when we find, as sometimes happens in such cases, that on re- 
turning to it the same symptoms constantly recur, and can not be 
prevented by changing the preparation, or the use of anodynes 
and mucilages, it must for the time be laid aside. 

Both because mercury seldom produces the effect here men- 
tioned, except when its use has been continued for some time, 
and because the effect is most apt to ensue when the bowels have 
been long exposed to other causes of irritation, we less frequent- 
ly have to contend with it in the first stage of Indigestion, which 
is the more fortunate, because the few substitutes for this medi- 
cine, wbich we possess, are less suited to the early than the more 
advanced stages in which it appears. From what is said above, the 
disease is not only essentially altered in its nature, but affects the 
system more generally. 

Some of the mineral acids are the best substitutes for mercury. 
A combination of the muriatic and nitric acids has appeared to 
me the most successful, whether taken internally or used exter- 
nally in the way recommended by Dr. Scott. 

This class of medicines are otherwise useful, we have seen, in 
the first stage of Indigestion; and if they maintain a due action of 
the liver, there is no occasion for the use of mercury. They sel- 
dom, however, have this effect for any length of time when its 
action has once been disordered; and they are much less calcu- 
lated than mercury for quickly restoring it, and hardly at all for 
suddenly emulging the biliary ducts, the effects which we look for 
from mercury in the first stage of Indigestion. I shall have oc- 
casion to make some further observations on the use of the mine- 
ral acids, in speaking of the treatment of the second stage. 

In some cases we shall find the dandelion an assistant to mer- 
cury, and under certain circumstances capable of being substi- 
tuted for it. It is defective in the same respects as the acids, and 
has the additional disadvantage of often being oppressive to the 
stomach in considerable doses, and in small doses it is of little or 
no use. 

From a want of attention to the circumstances under which 



1 



116 OF THE TREATMENT 

medicines should be employed, many fall into disrepute, which 
are capable of excellent effects when used more judiciously. We 
are too apt to fall into the practice of viewing a certain set of 
medicines as calculated to remove a certain disease, and, as one 
fails, to use another, without much attention to the properties pe- 
culiar to each, or the circumstances of the disease to which these 
peculiar properties are adapted. If we have recourse to the acids 
or the dandelion, wherever mercury does not afford the usual re- 
lief, we shall often be disappointed. If we employ them in the 
cases I shall soon have occasion to point out, they will seldom, as 
far as experience enables me to judge, fail to be useful. 

The treatment of the first stage of Indigestion, then, consists in 
promoting the due action of the stomach and bowels, by the va- 
rious means which have been detailed; and correcting the secre- 
tion of the liver, if it deviates from the healthy state, by the oc- 
casional use of mercury, care being taken neither to employ it in 
greater quantity, nor for a longer time, than is necessary lor this 
purpose, as its effects on the stomach and bowels are evidently in 
opposition to the other parts of the treatment. 

SECTION II. 

Of the Treatment of the Second Stage of Indigestion, 

It appears from what was said of the symptoms of Indigestion, 
that they are liable, after the disease has lasted sometime, to un- 
dergo a considerable change; the epigastrium becoming tender 
on pressure, the pulse hard, and some tendency to fever super- 
vening. These symptoms characterize what I have called the 
second stage of the disease. 

The period at which this change happens, we have seen, is 
nearly as various as that at which the deranged function of the 
liver shows itself, which it sometimes accompanies from its first 
appearance, but hardly ever precedes. In most cases, the above 
symptoms do not supervene till the function of this organ has 
been disordered for some time, or its disordered state has repeat- 



OF INDIGESTION. 117 

edly occurred. It may also be observed, that, like the disorder- 
ed state of that function, they are apt to come and go for some 
time before they are established. This is true, even of the ten- 
derness in the epigastrium. On one day it shall be considerable, 
and, even on the next, without the use of medicine, it shall have 
disappeared. In most cases, however, it is more stationary from 
the first, and, if the disease lasts, it always becomes so. 

As soon as the symptoms characterizing the second stage are 
established, we find that bitters and aromatics cease to give any 
effectual relief; and in many cases, the most stimulating in par- 
ticular, increase the feverish restlessness that occasionally assails 
the patient, and that languor and uneasiness which seldom whol- 
ly leave him. If, in consequence of his increasing complaints of 
debility, his medicines are changed for others of a more strength- 
ening nature, the effects are still worse; and he often thinks that 
his disease admits of no relief, but from aperients and particu- 
larly mercurial aperients, of the good effects of which he is al- 
ways sensible, and, consequently, is very apt to fall into an ex- 
cessive use of them: and many medical men appear to have ar- 
rived at nearly the same conclusion, for it is not unusual to find 
them declaring, that they see little good done in such cases ex- 
cept by purgatives and mercurials, a principle which has some» 
times been applied even to the earlier stages. 

Unless I have been deceived by a pretty extensive experience 
of the phenomena of this disease, there is no stage of it to which 
this conclusion is applicable. We have seen that purgatives and 
mercurials, properly employed, are valuable medicines in the first 
stage. We shall also find them so in that we are about to consi- 
der. But in both they are only part of the means, and, if em- 
ployed too freely, and to the neglect of others, will in all cases 
do mischief. 

The inflammatory symptoms of the second stage of Indigestion, 
led me to adopt a practice founded on them, and the immediate 
relief obtained, confirmed the views which had suggested it. 

The stimulating plan, which is proper while the fault is in the 
muscular and nervous powers of the stomach alone, is no longer 



118 OF THE TREATMENT 

applicable. The disease, however, still so far partakes of its ori- 
ginal nature, that, were we to regulate the treatment by an atten- 
tion to the inflammatory symptoms alone, the powers of the sys- 
tem would soon sink under it 

The more powerful anti-inflammatory measures, therefore, a 
very low diet, general blood letting, &c, are rarely proper, un- 
less, as sometimes happens, the inflammatory symptoms increase 
to those of active inflammation. The disease is then of a differ- 
ent nature, and must be treated on the same principles, although 
w 7 ith more than usual caution, as other phlegmasiae. The less sti- 
mulating of the tonic means employed in the first stage, on the 
other hand, are still indicated; the extent to which the one or 
other set of means should be carried, being regulated by the great- 
er or less degree of the inflammatory tendency. 

In two other respects, the principles of the treatment in the 
first and second stages of Indigestion differ. In the enumeration 
of their symptoms, we have seen, that although various other 
functions suffer more or less by sympathy with those of the di- 
gestive organs, almost from the commencement of the disease, 
it is in the second stage, both from the longer continuance of the 
derangement of the central parts, and from the greater severity 
and more complicated nature of that derangement, that they suf- 
fer most. Their affections, therefore, here influence the indica- 
tions of cure more than in the first stage; and as the strength is 
more impaired in the second stage, while the means of relief, at 
the same time, are of a more debilitating nature, an uniform en- 
deavour to preserve, as much as possible, that which remains, is 
here more indispensable. Evacuations, which, while the vigour 
of the system is comparatively entire, and the patient can be sup- 
ported by stimulating diet and medicines, have the best ef- 
fects; at a later period, and where less stimulating means alone 
are applicable, may be attended with serious injury. The sys- 
tem not rallying now, as in the first stage, the effect of one de- 
bilitating measure is still felt, when we are called upon for 
another; and, if our plans are not regulated with caution, and so 
directed as at no great distance of time to restore the proper 



OP INDIGESTION. 119 

functions, and thus render a continuance of such measures unne- 
cessary, the patient sinks equally under his disease and the means 
employed to relieve it. 

Such then are the principles on which, as far as I am capa- 
ble of judging from repeated experience of the various plans 
which have been pursued in this disease, the proper treatment 
of the second stage is founded. An inflammatory tendency is 
superadded to the derangements which constitute the first stage; 
stimulating measures are therefore to be employed with more 
caution, and anti-inflammatory measures become more or less 
necessary. The diseased action has spread farther, and the 
strength is more reduced; our measures must therefore embrace 
a wider field of practice, and the strength must be husbanded 
with greater care. 

We are now to consider more in detail the means, to the em- 
ployment of which these principles lead. I shall, in the first 
place, lay before the reader that part of the treatment, which 
forms the characteristic difference between it, and that we have 
been considering; and then point out how those means, which 
are common to both stages, should be modified in the one before 
us. We shall next consider such additional means as do not be- 
long to the treatment of the first stagey but can not, like the anti- 
inflammatory means, be regarded as in opposition to the plans 
there pursued; and in the last place, take a view of the treatment 
of the sympathetic affections which attend the second stage, and 
require means directed to the organs they affect. These we have 
seen immediately lead to change of structure, and may, therefore, 
be regarded as the link, which connects the second and third 
stages of this varied disease. 

The first thing, which appeared to me to throw much light on 
the nature and treatment of the second stage of Indigestion, was 
the effect of applying leeches to the tender part of the epigastrium. 
It was not, I found, merely that the tenderness was relieved, and 
the pulse softened; but that the patient breathed and walked bet- 
ter, that the bowels were more easily moved, and the skin ap- 
peared more relaxed, the feverish tendency which frequently 
shows itself in the evening, being in the same degree lessened. 



120 OF THE TREATMENT 

From these observations it appeared, that the effect of the 
leeches was not that of mitigating any particular symptoms, but 
of relieving the cause of the whole; because it is only on this sup- 
position that such general relief could be afforded. 

But even these, I found, were not the whole effect of the local 
blood-letting. On resuming the plan of treatment, it soon ap- 
peared, that the patient bore the use of tonics much better than 
before; and in some instances, a recurrence to the treatment of 
the first stage, under such circumstances, removed the disease. 
It seemed to have been the slight inflammatory action, which the 
leeches relieved, that alone had prevented the beneficial effects 
of these means I have thus had many opportunities of seeing 
the patient, after the use of the leeches, quickly restored to health 
by a plan, little different from that which had previously been 
employed in vain, and sometimes with an aggravation of the 
symptoms. 

But so fortunate an issue, I soon found, was only to be expect- 
ed where the second stage had been of very short duration, or the 
constitution was particularly favourable. On the tonic plan being 
resumed, the tenderness of the epigastrium was generally soon re- 
newed, and a repetition of leeches became necessary. Each re- 
petition to the same extent generally produced less relief than the 
preceding, and if a larger quantity of blood was taken, the relief 
was obtained at too great an expense of strength. 

The application of a blister to the part from which the blood 
was taken, immediately after its abstraction, tended both to in- 
crease the effect of the leeches, and render it more permanent; 
but, even w r ith this aid, their repetition in the more inflammatory 
cases soon became necessary. In those less inflammatory, blis- 
ters sometimes relieved the symptoms without the aid of leeches, 
but like the leeches they often failed to give permanent relief. 

Other measures, therefore, were requisite. The first that oc- 
curred was to abandon, in such cases, the more stimulating parts 
of the treatment, and although the patient generally felt a degree 
of sinking and debility from this change, particularly if made too 
suddenly, these symptoms were less permanent than when re- 



OF INDIGESTION. 121 

peated bleedings were employed, and the constitution gradually 
accommodated itself to the change. 

The lighter bitters and those stimulants whose effects are com- 
paratively more exerted on the nervous than the sanguiferous sys- 
tem, could in general still be borne. Among many hundreds, I 
have seen but few who could not bear the occasional, though not 
the regular use of aromatics, or even of ammonia and some of 
its preparations; and all could take the infusion of camomile 
flowers or bitter orange-peel, with the exception of those whose 
peculiarity of constitution did not admit of the use of bitters at 
any time: and with regard to diet, although in the more confirmed 
cases few could bear well the most stimulating kinds of meat, 
particularly beef, a little chicken daily, or once in two days, was 
generally borne without inconvenience, and supported the strength 
more, and agreed better with the stomach, than a diet composed 
wholly of vegetable food. 

Nor have I found it necessary in such cases wholly to abstain 
from the use of wine, although it has generally been advisable 
to lessen its quantity, and often to take it diluted. It is seldom, 
I believe, proper to reduce the diet more than this, unless active 
inflammation be threatened. In a few, particularly when a con- 
siderable degree of hardness of pulse, notwithstanding the use of 
the above means, continued, 1 have seen a diet wholly vegetable 
and even a total abstinence from wine, which is much less per- 
manently stimulating than animal food, strikingly beneficial. It 
is common for the appetite to improve on lessening the quantity of 
animal food. This depends in part on other food affording a less 
proportion of nourishment, but very much, I believe, on the ten- 
dency to fever being lessened by the change. 

The state of the bowels in such cases is often influenced by the 
diet in a very remarkable manner. They are not only torpid un- 
der the use of animal food, but purgatives act imperfectly, and 
with great irritation. On using a vegetable diet, they are fre- 
quently relaxed without the aid of medicine; and if purgatives 
are still necessary, they act in much smaller doses, and without 

irritation. It has generally been found better, however, to obvi- 
16 



122 OF THE TREATMENT 

ate the inflammatory tendency by other means, than to adopt so 
low a diet as very essentially to reduce the strength. 

Of all the medicines which I have employed with this view, I 
have found none equal to nitrate of potash taken in a considerable 
quantity of water, in which a little gum had been dissolved. 
The gum seems by defending, in some degree, the stomach and 
bowels from the irritation of their contents, which tends to coun- 
teract the cooling property of the nitrate, to add sensibly to its 
effect. If much be added, however, it is apt to oppress the sto- 
mach. Eight or ten grains of nitre in an ounce and a half of 
water, with a twelfth or sixteenth part of mucilage of acacia, 
have been given three times a day, and repeated every hour or 
hour and half, when the skin became hot generally, or the hands 
and feet began to burn. Two or three doses thus taken seldom 
fail to reduce the increased temperature, and relieve the restless- 
ness which it occasions; and thus simple as these means are, 
they often procure good nights, when the want of sleep, as fre- 
quently happens in this stage of the disease, is the effect of fever- 
ishness. The common saline draught, the sulphate of potash and 
other medicines of this description have similar effects, but none 
of them appear to me equal to the above nitrate.* 

It is not to be overlooked, however, that all medicines of this 
description are debilitating. I have known injury done by two 
free a use of them, the powers of the stomach being farther en- 
feebled, and a state of greater general, nervous debility superven- 
ing. In general, it is only when they are used incautiously, that 
these effects are to be apprehended. I have met with a few, in 
whom even small doses of the nitrate of potash occasioned irri- 
tation and debility. 

In addition to the foregoing means, rather a freer use of aperi- 
ents than in the first stage has been found useful. Aperients not 

* The carbonic acid gas, disengaged when the saline draught is taken in 
a state of effervescence, is grateful to many stomachs; to others it is op- 
pressive, and the draught seems to agree better with the stomach when the 
effervescence has been allowed to subside. I may here observe, by the by, 
that both from the extraction of air being apt to. oppress, and because they 
more readily combine with the acid of the first passages, the pure alcalis 
are sometimes found belter correctors of acidity than their carbonates. 



OP INDIGESTION. 123 

only promote the action of the bowels in expelling their contents, 
but occasion a freer ilow into them of the bile and pancreatic 
fluid, and of the fluids of the various glands of the canal itself. 
We have also, indeed, reason to believe that they stimulate the 
absorbent, as well as excreting vessels, a languid state of the 
bowels being unfavourable to nutrition. 

The disease, however, partakes too much of the chronic nature 
to admit of great evacuations of any kind; and, although the free 
action of the bowels is indicated here, not only as a means of ex- 
citing the various functions of the canal, but of allaying inflam- 
matory action, I have seldom found more than three evacuations 
in the twenty-four hours proper; and even this degree of catharsis 
should not be continued for many days together, for although the 
call for it is greater than in the first stage, the strength is often 
less able to bear it. Constipation, on the other hand, should be 
very carefully avoided, both from the direct injury it does, and 
because it is difficult to remove it without means, which risk too 
great an effect. Purgatives, on the whole, can hardly be here 
regarded as among the means employed for the purpose of reliev- 
ing inflammatory action. They must be used chiefly for the 
same purposes as in the first stage, and consequently belong rather 
to the means we are next to consider. 

When the inflammatory symptoms continue to recur after the 
temporary relief obtained by the preceding means, a perpetual 
drain, established in the most tender part, is often followed with 
the best effects. I have seen many cases, with this aid, yield to 
the means which they had long resisted without it. 

With regard to the modification, in the second stage, of the 
means common to both stages, in considering the anti-inflamma- 
tory measures suited to that stage, I have necessarily been led to 
make such observations on diet, aperients, and the use of stimu- 
lants and other tonics, as apply to it. 

When the first stage of Indigestion, we have seen, has continu- 
ed for some time, the function of the liver becomes disordered. 
A greater or less tendency to disorder in this organ, after it once 
appears, always continues throughout the disease, so that it is a 



( 



124 OF THE TREATMENT 

constant attendant on the second stage; and those medicines which 
influence the secretion of this organ, therefore, always form part 
of its treatment. Ot these we still find mercury by far the most 
efficacious. 

Several circumstances render caution, in the use of this medi- 
cine, even more necessary in the second than in the first stage. 
Not only has the greater continuance of the disease occasioned a 
greater loss of strength, but its increase and the change which has 
taken place in its nature, renders it necessary to employ this 
medicine for a longer time, and often in a way that more direct- 
ly influences the state of the constitution. 

In the first stage, we have seen, we want only the local effect of 
the medicine on the stomach and bowels; and in the earlier peri- 
ods of the second stage, and in mild cases, even after the disease 
has continued for a long time, we still find that this effect of it, 
particularly of the blue pill, repeated for a longer time, is often 
sufficient, especially when the anti-inflammatory measures we 
have been considering are duly employed. 

When it is sufficient, no other should be attempted. But in 
many cases, and .in a large proportion of those of long standing, 
it fails, The relief afforded by the occasional doses of mercury 
gradually becomes less, and they at length cease to be of any es- 
sential use. 

When it is given in such doses, indeed, as to produce a con- 
siderable effect upon the bowels, partial relief is still often obtain- 
ed, but the strength rapidly fails under this employment of it; and 
the relief afforded does not extend to the most essential part of the 
disease. While the patient is relieved for the moment, we find 
the slow change which leads to the disorganization of some vital 
part going on, and constantly occasioning a renewal of the symp- 
toms; which are thus relieved at an expense of strength, that ac- 
celerates the fatal termination; and, beneficial as occasional doses 
of mercury usually are in the earlier periods and milder forms of 
the disease, it may often be questioned whether in confirmed cases 
they do more good or harm. 

Finding so little advantage from the usual mode of giving mer- 



OF INDIGESTION. 125 

cury, in the second stage of Indigestion, when it does not soon . 
show a tendency to yield, and that all means are so generally 
unsuccessful in the last stage, which, in such cases, is always at 
hand, it occurred to me to try the effect of more frequently repeat- 
ed doses of this medicine, so small, that if they did little good, no- 
thing, at least, was to be apprehended from them. 

I have generally given a grain of the blue pill, sometimes only- 
half a grain, twice or three times in twenty-four hours, till the 
secretion of bile appeared to be healthy, repeating these doses 
when it was again disordered; and by such doses, which may ap- 
pear to many little better than trifling, I have seen the bile gradu- 
ally restored to a healthy state, when larger doses had been em- 
ployed in vain. They not only often succeed where larger doses 
fail, but the change, in proportion as it takes place more slowly, 
seems generally to be more permanent. 

The correction of the state of the bile, however, is but one of 
the effects of such a plan. Along with its improvement, the 
skin generally becomes relaxed, and of a proper temperature, the 
pulse more dilated, the colour and expression of the countenance ■ 
better; and, in particular, that expression of langour, so peculiar' 
to the advanced stages of the disease, abates. As all these changes 
depend on a common cause, and consequently take place toge- 
ther, the state of the bile, which should from time to time be ascer- 
tained, is a good indication of the general effects of the medicine. 
It is true that the most transitory effects of mercury, when they 
correct the state of the liver, at the same time produce many of 
the foregoing effects in other organs, the diseased state of which is 
supported by sympathy, with that of the alimentary canal. But 
this is chiefly observed in the first, or the milder cases of the 
second stage; while in the more serious cases, the affection of 
these organs, we have seen from its frequent recurrence and 
longer continuance, becoming more obstinate and less immediate- 
ly dependent on the original disease, resists the occasional exhi- 
bition of the medicine. 

On this the good effects of the plan, I am here considering, 
seem chiefly to depend. By the mercury being given in such 



OF THE TREATMENT 

minute closes, it enters the system, and acts directly on the various 
organs, now too much implicated in the disease to yield to its 
sympathetic effect, yet, by the smallness of the quantity, it is 
unattended by the bad consequences of what is called a course of 
mercury. 

The beneficial effects of this plan appearing slowly at first, dis- 
courages the hopes of the physician, and, as I know, in many in- 
stances, has caused it to be laid aside. It is difficult besides to 
persuade the patient that any plan which produces no immediate 
sensible effect, can be mm h relied on; for I have always made it 
a rule to discontinue the mercury even in this stage of the disease, 
when the slightest affection of the mouth appeared, and any de- 
gree of salivation has generally seemed to me to do more harm than 
good. 

It is nearly twenty years since I first adopted this mode of using 
mercury in the case before us, and I have now great satisfaction 
in stating, that several men of experience, in our profession, who, 
at first, believing that no good could result from such minute 
doses, viewed the practice as little better than a waste of time, 
have since confessed, that it gave a degree of relief which could 
not be procured by larger doses. This, and my own repeated 
experience of its effects, enable me to speak of them with con- 
fidence. 

Although we do not thus obtain the sudden benefit which re- 
sults from a more vigorous practice, we avoid the mischief it of- 
ten does; and whatever good effect is produced, is allowed, if I 
may use the expression, to accumulate in the constitution. We 
are not undoing on the one hand, what is done on the other, which, 
with all the care that can be taken, is very often the case when 
larger doses are employed. 

It is almost unnecessary to observe, after what has been said, 
that to render the plan most successful, the various observations 
respecting diet and exercise, and the occasional aids of cathartics, 
local blood-letting, blisters and cooling medicines, must constant- 
ly be kept in view; and if the blue pill occasion any irritation of 
the bowels, which sometimes arises even from the doses here re- 
commended, it must be obviated by anodynes. 



OF INDIGESTION. 127 

For this purpose I have found the extract of poppies, conium, 
and hyoscyamus, the best means; and I have, for the last eight 
or ten years, been in the habit of combining equal quantities of 
the last of these with the blue pill, as a preventive; and have ex- 
perienced from it not only this advantage, but some good from its 
general sedative effect on the system; and it will easily be believ- 
ed, that the extract of hyoscyamus in doses not exceeding a grain, 
given two or three times a day, never produces inconvenience of 
any kind. 

If the irritation, occasioned by the internal use of the mercury, 
can not be allayed, its external use may here be tried, the dose 
being proportioned to that recommended internally. From a 
scruple to half a drachm of the weak mercurial ointment may be 
rubbed iuto the skin every evening. This way of employing it, 
however, is objectionable in the case before us; by it the medicine 
is less effectually applied to the chief seat of the disease, and the 
quantity received is much less easily ascertained. I have already 
had occasion to observe, indeed, that the external use of mercury 
seldom has much effect in correcting the state of the bile, till it 
produces some effect on the mouth. 

If even this use of it irritate the bowels, which may happen, 
particularly in the advanced stages, when they have already suf- 
fered much from the medicine, and we can not obviate that ef- 
fect, it must be discontinued; and only renewed at intervals, for 
the time that the bowels can bear it without irritation. Beyond 
this even the smallest doses do more harm than good. 

In the few constitutions, in which no dose of the blue pill can 
be taken without disordering the stomach, I have substituted for 
it, with good effect, a sixth or eighth part of a grain of calomel, 
combined with some anodyne, but this preparation is not so well 
suited to the objects in view. 

It is not uncommon in all constitutions, for a few grains of the 
blue pill to occasion a slight pain referred to the stomach soon af- 
ter it is taken, which continues for half an hour or more, and this 
symptom sometimes arises from smaller doses; but it is seldom ot 
much importance, and often ceases to recur after a few doses have 
been taken. 



128 OF THE TREATMENT 

I have not found it necessary to confine the patient under the 
foregoing plan, while his strength is equal to the exertion of going 
abroad; except at night and in bad weather; and this degree of 
confinement his disease requires independently of medicine. 

I have had occasion to observe that it is to the second, rather 
than the first, stage, that the substitutes for mercury are best 
adapted, and that the mineral acids, particularly a combination of 
the muriatic and nitric acids, and the dandelion appears to be 
the best. 

Much has of late been said of the external use of these acids. 
Both their internal and external use has appeared to me best 
adapted to cases of some continuance, where the inflammatory 
tendency has been to a great degree subdued, and small doses of 
mercury have been employed without the usual benefit. In 
such cases, I believe, the use of the acids will almost always be 
found better than increasing the quantity of mercury beyond what 
produces the slightest indication of its presence in the gums. If 
the habit bear the mercury well, the acid may be used in aid of 
it; if not, or if the use of the acid, as sometimes happens, causes 
the mercury to irritate the bowels, the latter should be discon- 
tinued under the use of the acid. 

When the mercury, either on account of its effects on the bow- 
els, or the debilitated state of the patient, can only be used at 
intervals, the intermediate use of the acids is generally of con- 
siderable service. They tend at once to restore the strength and 
prolong the effects of the mercury. According to my experience, 
the external use of the acids, recommended by Dr. Scott, is more 
powerful, both as a substitute for mercury, and a means of cor- 
recting its debilitating effects, than internal use. It consequent- 
ly requires more caution, where there are any considerable re- 
mains of the inflammatory diathesis; I have known it produce an 
alarming increase of the inflammatory symptoms. 

The dandelion appears to possess greater powers in this disease 
than are usually ascribed to it, but it requires to be taken in very 
large doses. It is best adapted to those cases, in which the bile 
is deficient or much disordered, while the power of the stomach 



OF INDIGESTION. 129 

is still considerable. In such cases, I have seen the patient re- 
stored by a strong decoction of dandelion used tor common drink, 
without the aid of any other medicine. In addition to its effect 
on the liver, it tends to cool, and consequently allay the inflam- 
matory diathesis, and often excites both the bowels and kidneys. 
The latter effect, which is best counteracted by alum, when the 
stomach bears it well, is frequently such as to make it necessary 
to discontinue the dandelion. The former is seldom considera- 
ble, and can always be restrained. It is often given with great 
advantage in aid of the small doses of mercury when the stomach 
bears it well, and enables us further to diminish the quantity of 
this medicine. I shall have occasion to make some additional 
observations on it in speaking of the treatment in the third stage 
ef Indigestion. 

Besides the means, the more prominent effect of which is, that 
of correcting the secretion of bile, there are others often useful, 
particularly after the general inflammatory tendency has been 
subdued, and debility becomes the most urgent symptom, which 
seem to act more uniformly on all the secreting surfaces. For 
this we are prepared by what has already been said. 

We have seen the secondary affections in this disease gradually 
gaining importance in its progress, and, that if no vital organ is 
so much weaker than the rest, that the disease fixes on it, produ- 
cing effects which we are presently to consider, the various or- 
gans which have from the first suffered by sympathy, have their 
powers more permanently impaired; and the disease gradually 
assumes the form rather of a case of general, and for the most 
part obstinate, debility, than a disease of any one set of organs. 

This form it assumes the more readily, in consequence of a 
law of the animal economy which has often attracted our atten- 
tion; namely, that although the sympathetic affections produced 
by a disease, tend to increase the original affection, in proportion 
as the secondary affection begins to be changed into actual dis- 
ease of the part, it tends to relieve the disease from which it 
sprung. Hence it is, that in the case we are speaking of, in pro- 
portion as debility of other parts becomes permanent and inde- 
17 



130 OF THE TREATMENT 

pendent of the cause which produced it, the digestive organs are 
frequently relieved. It is not uncommon for patients in the state 
I am speaking of to express their surprise, that they should be so 
weak, when the stomach performs its office so much better than- 
when they felt comparatively little of this general debility. 

The state of the disease before us necessarily supervenes more 
readily in some than in others; according as the organs seconda- 
rily affected are more liable to disease, and no particular organ 
so much weaker than the rest as to induce the disease to fix par- 
ticularly in it. 

We have now, in some degree, a new disease to contend with. 
The general sympathetic disease has become that of most im- 
portance. Even in this case, however, the pulse is still more or 
less contracted, and a degree of hardness will be readily perceiv- 
ed in it, if it be examined in the way which has been pointed 
out; a circumstance, which, with the history of the disease, and 
some uneasiness being still caused by pressure in the above-men- 
tioned part of the epigastrium, readily distinguishes this state 
from other cases of debility. 

The remains of the original disease to be observed in such 
cases, together with the good effects which often, for the time, 
result from every thing which generally excites the secreting sur- 
faces, frequently induce physicians still to look to mercury, given 
in what is called an alterative course, that is, in doses taken at 
considerable intervals, as the chief means of relief in such cases; 
the propriety of which I think many circumstances must lead us 
to question. 

Before the disease arrives at this period, every power of the 
constitution has been strained by it, and not unfrequently by the 
means employed for its relief. From mercury in particular, it 
has generally suffered much; and the bad effects of medicine, 
like all other morbid affections, gaining force by habit, we see 
those of mercury now appear from doses, which, at an earlier pe- 
riod, would have produced no sensible derangement. 

There is also another point of importance to be considered in 
such cases. The general debility produced by mercury, when it 



OF INDIGESTION. 131 

is given for the removal of a local disease, is, particularly if it 
has been successful in removing it, more or less readily corrected, 
the functions in general being healthy. But in the case before 
us, where they are in a state of disease, it is corrected, if it be 
corrected, at all, with great difficulty. 

If to the foregoing circumstances we add, that, powerful as 
mercury often is in exciting the due action of the secreting sur- 
faces in general, it is by no means so powerful a remedy in this 
respect as in correcting disorder of the hepatic system, the skin 
and other secreting surfaces often remaining obstinately inactive 
under its use; and that if it fail to excite the secreting surfaces, 
its general effects on the system must add to their debility : we shall 
admit, I think, not only that little is to be expected from it in 
the case before us, but, as far as we can judge from the known 
effects of this medicine, and the nature of the disease, there is 
great risk of its increasing the evil. This inference, however, is 
not alone the result of reasoning. If we carefully watch its ef- 
fects, according to any experience I have had in such cases, they 
will be found to correspond with it. However it may relieve for 
a little, when resumed after a long interval, its good effects soon 
disappear, and the only consequences of continuing its employ- 
ment seem then to be, to add to the debility and hasten the pro- 
gress of the disease. 

Although the state I am speaking of may be considered as 
comparatively rare, for it is much more common for the diseased 
action, which has long existed in obstinate cases of indigestion, 
to fix principally on one organ, than to produce the general state 
of debility I am here considering; yet we very frequently meet 
with a state resembling this, before the disease finally fixes on 
one organ; and particularly in the intervals between the attacks 
of disease, which that organ generally suffers, before actual 
change of structure commences in it. To this state, the obser- 
vations just made, and those I am about to make, equally apply 
as to that where no organ suffers in particular; except that in the 
former, the means which influence the whole system, must be 
combined with those directed to the organ chiefly affected, which 
we are presently to consider. 



132 OP THE TREATMENT 

I have found the debility most obstinate when least complica- 
ted with the determination to particular parts, provided change 
of structure had not taken place in the latter case. The inflam- 
matory tendency, we have seen, is still shown by the hard pulse, 
which is relieved with difficulty; because, not depending on the 
affection of any one part, local evacuations influence it but little, 
nor are they at all the appropriate remedy; and the general state 
of debility admits of but a very cautious use of those which pro- 
duce their effect on the whole system. 

Blood-letting is here out of the question. The pulse must be 
softened by a mild diet and medicines which excite the secreting 
surfaces, but mercury, we have just seen, is objectionable. The 
moderate use of saline mpdicines is among the best means in such 
cases. It would surprise any one whose attention had not been 
particularly directed to them, to observe the effects which a diet, 
composed wholly of vegetable substances and milk, if the sto- 
mach can bear it, combined with small doses of such medicines, 
often produces in those labouring under this form of the disease; 
who have been vainly endeavouring to support their strength by 
a large proportion of animal food and tonic medicines. It has 
long been admitted, indeed^ that such a diet is sometimes useful 
in cases of debility. By this change, the pulse is more or less 
softened, and the bowels and the skin are relaxed. 

It unfortunately happens that the debility is generally such that 
some portion of animal food is necessary, and a diet wholly com- 
posed of vegetable matter is often apt to renew the symptoms of 
Indigestion. A little of the milder kinds of animal food, there- 
fore, is for the most part necessary, but I have generally seen the 
best effects from abstaining from it every second or third day. 

Great advantage has appeared to me to arise, in the case 
before us, from sarsaparilla, the continued use of which often 
seems to give a general tendency to greater freedom in the se- 
creting surfaces. I have repeatedly seen it, by its mild stimulant 
and tonic powers, succeed where every thing else had failed. 

I have also seen strikingly good effects, when the pulse was 
much contracted, and the skin shrunk and cold, from very small 



OP INDIGESTION, 133 

doses ofcolchicum; but, like other medicines of this description, 
it must be used with caution, and no further than is necessary to 
soften the skin and the pulse. Antimonial medicines, in altera- 
tive doses, are sometimes useful, but in general they debilitate too 
much to be long continued, and their effects soon cease when 
they are laid aside. The effects of both these medicines, parti- 
cularly the former, are often improved by combining them with 
the small doses of opium above mentioned. 

We may infer, from what was said of the effect of a damp air 
in speaking of the causes of Indigestion, that a clear and fresh 
air is often of the greatest use to the dyspeptic, and the states we 
are now considering require it more than those of an earlier 
period. 

A very sharp air, however, is unfavourable. It too much pro- 
motes the inflammatory tendency, and all sudden changes of 
weather, on this account, are injurious. It is thus that the spring 
is the most unfavourable season for invalids of this description; 
but a heavy still air never fails to depress their spirits and in- 
crease the whole train of nervous symptoms. 

I have often, during a long residence in a town where the air 
is too close, both from its low situatiou and the flat and wooded 
state of the country, seen these observations strikingly illustrated. 
Patients of this description drooped in the town, but on being re- 
moved to the neighbouring hills of Malvern, immediately revived; 
and those who at Malvern enjoyed good health, often had a re- 
newal of their nervous and bilious complaints on coming to the 
closer air. 

A free and mild air, a mild and easily digestible diet, regular 
exercise proportioned to the strength', a regular state o' the bowels, 
a moderate use of saline medicines at the times when the general 
temperature is increased, or there is a sensation of burning in the 
hands and feet, and the use of sarsaparilla when it does not op- 
press the stomach, and such other medicines as excite the secret- 
ing surfaces generally without materially impairing the strength, 
I would say, constitute, according to my experience, the outlines 
of the best plan in such cases; and I believe mischief is always 
done by powerful measures. 



134 OP THE TREATMENT 

It is necessary to make the patient sufficiently acquainted with 
his case to be satisfied with very .gradual amendment, I relieve 
mercury should now make no other part of the treatment than in 
the first stage of the disease. It should only be employed for 
restoring due action to the liver when this considerably deviates 
from the healthy state, and then in as small quantity, for as short 
a time, and with as little impression on the general system as 
possible. 

When other means fail, a voyage and change of climate are of- 
ten ol service; and I believe the waters of Buxton are sometimes 
useful. 

What is called change of air, indeed, although in the same cli- 
mate, is almost always beneficial in Indigestion, and particularly 
in the advanced stages. I shall take, the present opportunity to 
lay before the reader the observations which have occurred to 
me on this subject. 

There has been much difference of opinion respecting the cause 
to which the benefit derived from change of place is to be ascrib- 
ed. We have reason to believe that it arises from various cir- 
cumstances, but least of all, in most instances, from mere change 
of air. It is evident that the air is effectually changed by the 
wind, and far more rapidly than it can be by any change of place. 
Yet it is only when the temperature or degree of moisture is 
changed by the wind, that we can perceive it produce any change 
in the health, if we except that a certain degree of wind is use- 
ful by preventing absolute stillness of the air, which always be- 
comes oppressive when long continued, and that, independently 
of any impregnation of the air, for it is felt by those who inhabit 
single bouses in the country,' as well as by the inhabitants of 
towns. A free circulation of air is particularly grateful to the 
feelings, and, as we might from this alone infer, favourable to 
health. 

The truth is, that the air is essentially the same in all places. 
It has been found by correct experiments, that in the closest parts 
of London and on the top of the Malvern Hills, it possesses the 
same proportion of the principle which supports animal life, and 



OP INDIGESTION. 135 

is itself, indeed, in all respects the same; but it is capable of being 
variously impregnated. The sense of smell at once informs 
those from the country, that the air of large towns is less unmix- 
ed than that which they have been accustomed to breathe. 

All impregnation of this kind must, we should at first view sup- 
pose, be more or less injurious, and to a certain degree it may be 
so; but we have reason to believe, I think, that it is much less 
so than the occasional greater dampness and chillness of the air 
of large towns, produced in the way pointed out in the second 
chapter, and the usual greater stillness of the air in them from 
confinement by the buildings. 

The chief impregnation of the air of large towns seems to be 
from smoke, which does not appear to be particularly unwhole- 
some. It has on the contrary indeed been supposed to preserve 
from disease, and has often been employed with this view. The 
other effluvia of such towns are in too small quantity to produce 
much impregnation of the external air. 

I have just had occasion to observe, that the change of air by 
the wind seems only to affect the health by the motion of the air 
it occasions, and by its influencing its temperature and degree of 
moisture. I am inclined to think that it is merely in these ways, 
which are doubtless in many cases very important, that change 
of place, as far as the air is concerned, affects us. The air i& 
self, I have just had occasion to observe, is always the same; and 
its impregnations, unless it be confined, are never, perhaps, such 
as sensibly to influence the health, if we except those states con- 
nected with the production of contagious diseases, which are very 
little understood.* But there are many other things in change 
of place capable of essentially influencing it, of which, I believe, 

* Some have been inclined to doubt whether the air is ever so changed 
as to produce disease, independently of the presence of contagion and the 
changes of its temperature and degree of moisture, but there are some 
well-ascertained facts which it is difficult to explain on any other supposi- 
tion. We see contagious diseases, particularly a plague, appearing and 
declining in different parts of the country, perhaps, hundreds of miles dis- 
tant from each other, at the same time and without any evident cause, 
which it would be difficult to account for by any of the known properties 
of contagion. I have elsewhere had occasion to consider this subject at 
some length.— 'Treatise on Fevers y p. 158, et seq. fourth edition. 



136 OP THE TREATMENT 

m 

the most powerful is the excitement given by the change itself. 
How often do we find continual change necessary, the new place 
being no better than the old, as soon as the novelty of the change 
is worn away. 

To the mere exercise of body occasioned by the travelling, or 
to which a new situation naturally incites, much must often be 
aseribed; but, I believe, we must look to the occupation and 
cheerfulness of mind occasioned by the change for its chief ef- 
fects. The feelings of sickness on the one band, like all other 
feelings, are soon associated with every thing around us; and on 
the other, the mind, if not forcibly abstracted, fixes intensely on 
any object, which for a long time chiefly occupies the attention. 
In long continued sickness, we want something to break that as- 
sociation, and something to divide our attention. What can so 
powerfully produce these effects as a total change of place? The 
poor in some parts of this country, who can not afford to send their 
children to a distance in the decline of hooping-cough, in which 
change of place is so powerful a remedy, confine them daily for 
a certain time close to the machinery of a mill, and this often 
answers the purpose as well. 

Let me add, those who ascribe to fancy all diseases which may 
be cured by change, know little of the nature of disease or the 
laws of the animal economy. Will they ascribe the hooping- 
cough to fancy, or eruptions and sores of the surface, pains and stiff- 
ness of the joints, and a thousand other ailments, which are often 
cured by change alone? We have seen how extensive the trains 
of diseases are, which in many cases depend on affections of the 
digestive organs; and how much these affections are influenced by 
the state of the mind, which is very nearly as much the subject 
of external circumstances as the body. 

In the cases, we have last been considering, the patient is not 
always much emaciated, and is sometimes full and bloated. This 
seems to arise from the waste being much lessened by a general 
failure of the secreting powers, and it is not uncommon for loss 
of flesh to be among the first symptoms of recovery. The in- 
creasing power of the organs of supply, if the recovery goes on. 
soon of course begins to counteract this effect. 



OP INDIGESTION. 137 

As these cases have seldom been accurately distinguished, 
their treatment must be regarded as in its infancy.* They are 
sometimes treated merely as cases of obstinate debility, and 
thus by the tonic means employed, the lurking inflammatory ten- 
dency is called into action; and often, at length, shows itself by 
some of the trains of symptoms, which now demand our attention, 
the particular consideration of which has, for reasons above stated, 
been referred to this place. 

Of certain Trains of Symptoms whose Treatment does 
not fall under the general Plan of Cure. 

It appears, from what I have already had occasion to say, that 
the symptoms which arise, when the sympathetic affections begin 
to have an existence, independent of the cause which produced 
them, and consequently to require a plan of treatment directed to 
the parts they affect, show themselves at earlier periods, as well 
as at the period which we have just been considering The ear- 
lier they show themselves, the inflammatory action generally rises 
the higher, the later they appear they are the more obstinate, and 
the more apt to occasion change of structure. This is at all times 
their tendency, and it is therefore, as I have already had occasion to 
remark, that they may be regarded as the link which connects 
what I have termed the second and third stages of Indigestion; 
the former characterized by the presence of the inflammatory 
tendency; the latter by the usual consequence of its continuance, 
change of structure in some vital part. 

The class of symptoms, of which I am speaking, more than 
any other, tends to render the disease complicated, and conse- 
quently, at first view, obscure; but a careful study of them un» 

* The green jaundice, of which Dr. Baillie gives so valuable an account 
in the fifth volume of the Transactions of the College of Physicians, is differ- * 
ent from these cases, incurable organic disease of the liver having almost al- 
ways taken place in it. In other respects the two states are similar, and it 
is particularly satisfactory to me, that the observations he makes on the treat- 
ment so nearly correspond with the result of my experience. I have also seen 
his observations on the prognosis, as well as the treatment of green jaun- 
dice strikingly confirmed. 

18 



138 OF THE TREATMENT 

folds its true nature, tbe manner in which it extends its influence 
throughout the system, and the steps by which it is capable of 
disorganizing any part of it. 

Some of its most striking features, we have seen, arise from 
the manner in which distant parts sympathize with the stomach. 
The nature of the affection of these parts, it was observed, cor- 
responds with that of the stomach itself. In the first stage they 
are mere nervous affections, ceasing as soon as the cause of irri- 
tation from which they arise ceases. In the second stage they 
become inflammatory affections, which have an existence inde- 
pendent of that cause; for the occurrence of the inflammatory 
tendency in the stomach, immediately produces the same tenden- 
cy throughout the system, to such a degree indeed, that inflam- 
mation readily arises in those parts of it which most sympathize 
with the stomach, even from causes not connected with the 
disease. 

The secondary symptoms of Indigestion are most easily excit- 
ed in infancy, and least so in advanced periods of life. In infan- 
cy too they are most speedily fatal; but it is from puberty to 
about forty years of age that they are most frequent, because 
at this period, their causes are most frequently applied, and the 
susceptioility of the constitution is not yet greatly impaired. Be- 
sides, after forty, we have seen, the disposition to Indigestion is 
less. 

It appears from the enumeration of the symptoms of Indigestion, 
that the liver is the first organ which partakes of the disease of 
the alimentary canal. In the first stage, we have seen that its 
function is generally deranged at an early period; and in the se- 
cond, that the inflammatory tendency of the pylorus in most cases, 
soon extends to it. It is also the organ which is most frequently 
the seat of those trains of symptoms, which we are now about to 
^consider. 

It is not uncommon in the second stage of Indigestion, when 
the patient takes cold, or is exposed to other causes of inflam- 
mation, or, indeed, without any evident cause, for the greater 
part of the right hypochondrium to become full and tender on 



OF INDIGESTION. 139 

pressure, with a sense of oppression and an increased hardness 
of pulse, often accompanied with some degree of dyspnoea and a 
dry teasing cough. He sometimes complains of pain in the right, 
not unfrequently in the left, hypochondrium, or in the pit of the 
stomach, or in the right, or sometimes the left shoulder, and ex- 
periences some uneasiness in lying on either side, particularly on 
the left, a greater than usual derangement of the biliary secretion 
accompanying these symptoms. In short, he evidently labours 
under inflammation of the liver. 

It is seldom, however, of the most active kind, requiring gene- 
ral blood-letting, which is fortunate, as patients of this description 
rarely bear loss of blood well. I have seen many who had long 
laboured under Indigestion unable to bear the necessary loss of 
blood, when attacked with acute inflammation. They are, bow- 
ever, comparatively, little liable to it. Their inflammatory at- 
tacks generally partake of the chronic nature of the habitual 
disease, and for the most part yield to local blood-letting and 
blisters with the aid of a mild diet and saline and aperient medi- 
cines. 

This treatment, combined with the small doses of blue pill, 
given in the way above pointed out, never fails to relieve the af- 
fection of the liver we are here considering, till its frequent re- 
currence has rendered it obstinate, and produced some tendency 
to change of structure. 

The pain, it has been just observed, is often felt in the left side, 
while the tenderness on pressure is wholly confined to the right; 
but, after the affection of the right side is relieved by evacuations 
from the tender part, it is not uncommon for the left side to be- 
come both full and tender, the inflammatory affection appearing 
to attack the spleen as soon as the liver is relieved from it; and it 
will, sometimes, on the fulness and tenderness of the left side 
being relieved by the same means, return to the liver. This al- 
teration I have seen happen more than once before the disease 
subsided, in those who had long laboured under the second stage 
of Indigestion. 

Sometimes, though much more rarely, the fulness and tender- 



140 



OP THE TREATMENT 



ness appear in the left side alone. The pain is then more confined 
to the sett of the tenderness. The same means are here proper, 
with the exception of the blue pill, which seldom seems to be of 
much service in this affection; and the employment of which 
must therefore be regulated by the state of the other symptoms. 

The chief seat of such attacks, however, is often in organs at 
a greater distance from that of the original disease. I shall, in 
the first place, mention the lower bowels, because these are more 
immediately connected with the disease, and are injured, not only 
by sympathy with the higher parts of the canal, but more direct- 
ly influenced by their vitiated secretions and the undigested food. 

The irritation of the bowels, which attends the first stage, is for 
the most part easily relieved by purgatives and anodynes. In the 
second stage it often becomes obstinate, and shows the same in- 
flammatory tendency which now characterizes the primary dis- 
ease. The hypogastrium becomes full and tender on pressure, 
and the irritation which exists there increases the general tenden- 
cy to fever. 

We should a priori expect that the lower bowels w 7 ould suffer 
more than other parts of the canal, especially when the disease 
is of long continuance, the morbid contents of all the rest passing 
by them. The sigmoid flexure of the colon appears to be the 
part most liable to he affected, probably from the contents 
lodging there longer than in other parts of the large intestines. 
It is not uncommon in protracted cases, to find a considerable de- 
gree of tenderness in the seat of this part, which is sometimes at 
length affected with ulceration. It is also, probably for similar 
reasons, common, though not so much so, to find tenderness on 
pressure in the seat of the coeeum. In other instances it is more 
general. 

Opening medicine, in such cases, seldom gives much relief, 
and often increases the irritation; nor have I found any means 
effectual without those which lessen the ii.flammatory state of the 
parts. The application of leeches to the part most tender on 
pressure, and the use of mucilaginous and anodyne clysters sel- 
dom tail to give relief, and then mild aperients generally succeed 



OF INDIGESTION. 141 



in procuring a free action of the bowels. It is sometimes ne- 
cessary to repeat these means, and when the symptoms are obsti- 
nate their good effects may be promoted by the tepid bath; but I 
have seldom found fomentations of the abdomen of much use, 
although a large poultice applied over the lower part of it some- 
times appears to be of service. 

Both from the passage of the vitiated contents of the bowels, 
and from the return of the blood through the hepatic system 
being rendered less free, those who have long laboured under In- 
digestion, are particularly subject to piles; great relief is general- 
ly obtained in the affection of the bowels, we are considering, 
when they bleed freely; and when they exist to a considerable 
degree without bleeding, the application of leeches to them is 
sometimes the best mode of letting blood in that affection. I 
have repeatedly observed, even where it had not gone the length 
of producing decided inflammatory symptoms, but the patient had 
for some days been teased by scanty, irritating and unsatisfacto- 
ry evacuations, that after a small spontaneous discharge of blood 
from the piles, the bowels have emptied themselves with freedom 
and ease. Foreign, particularly French, physicians, place great 
reliance on bleeding from the seat of the piles, even where no 
degree of this disease exists, in all inflammatory affections of the 
bowels. Dyspeptics we have seen are often subject to more or 
less permanent spasmodic stricture of the rectum, this is most 
apt to occur when some degree of inflammatory tendency in the 
bowels have supervened, and we have reason to believe that 
when frequently renewed it may end in organic stricture. This, 
however, is certainly not a frequent occurrence. When Indiges- 
tion is complicated with organic stricture of the rectum, it will 
generally be found, I believe, that the stricture is the primary 
disease. 

Every cause of irritation of the alimentary canal is apt to re- 
new the inflammatory tendency in the bowels, particularly the 
reptated use of mercurial medicines. It is also frequently re- 
newed by cold or other causes of inflammation. The best means 
of prevention are a very mild and rather mucilaginous diet and 
a free state of the canal. 



1 42 OF THE TREATMENT 

The chest frequently suffers in the second stage of Indigestion, 
the dyspnoea, which we have seen an occasional attendant at all 
periods of the disease, becomes more permanent, with a sense of 
oppression and difficulty of lying in the horizontal posture, and an 
increase of the tenderness of the epigastrium, the hardness of 
the pulse, and burning of the hands and feet The feeling of 
oppression is greater than seems to belong to the degree of the 
dyspnoea, and is much increased by all active exercise. A short 
dry cough sometimes attends, but is by no means a constant 
symptom; a circumstance which, with the absence of any thing 
that deserves the name of fever, often deceives respecting the in- 
flammatory nature of the affection. Biisters generally give relief, 
but we still find local blood-letting the most certain and expedi- 
tious means. 

The increase of the tenderness of the epigastrium, hard pulse, 
and feverish symptoms distinguish this affection from another 
species of permanent dyspnoea, which we found a frequent at- 
tendant on Indigestion, and which I shall soon have occasion 
more particularly to consider. It seems to be wholly a nervous 
affection, and frequently to be the effect of repeated attacks of 
the inflammatory dyspnoea, which is still apt to be reneweo, and 
consequently to become complicated with it, when the patient is 
exposed to taking cold or any other cause of inflammation. 

Palpitation we have seen is sometimes a symptom of Indiges- 
tion, and is, for the most part, readily relieved by means already 
pointed out; but in some instances the affection of the heart be- 
comes so obstinate, that I have repeatedly known it assume the 
form of angina pectoris, and be treated in vain as such, for seve- 
ral years; yielding, at length, to means which restored due power 
to the digestive organs. All affections of the heart becoming ob- 
stinate in the second stage of Indigestion with an increased hard- 
ness of pulse, are relieved by loss of blood; and I have seen de- 
cided carditis supervene under such circumstances, requiring the 
frequent repetition of copious general blood-letting. 

It is a common observation that carditis is apt to supervene after 
repeated attacks of rheumatic pains of the limbs. I believe from 



OF INDIGESTION. 143 

many cases which have fallen under my observation, that it will 
generally be found in such instances, that the rheumatic pains 
had been combined with, and in a greater or less degree depen- 
dent on, disorder of the digestive organs. 

The pains of the limbs arising from this cause, will often com- 
pletely assume the form of rheumatism, and become very obsti- 
nate, if the cause which supports them be overlooked; which is 
the more likely to happen, because here, as in other cases, cold 
is very often their immediate exciting cause, I have seen severe 
pains of the limbs which had long resisted the means usually suc- 
cessful in rheumatic cases, wholly removed, by combining with 
these means, the treatment adapted to the second stage of Indi- 
gestion. 

But of all the sympathetic affections of distant parts in Indi- 
gestion, none are so frequent as those of the head. In the second 
stage, they usually assume the same inflammatory character with 
the other affections belonging to this stage. From the function 
and situation of the brain, however, the nervous affections of this 
organ connected with a diseased state of the stomach, assume a 
more formidable appearance than those of other parts, and con- 
sequently demand more attention. After considering the former, 
therefore, I shall lay before the reader the observations which my 
experience of the latter has suggested. 

Head-ach, we have seen, is one of the most common symp- 
toms, both of the first and second stage of the disease, sometimes, 
indeed, Indigestion shows itself only by this symptom. In the 
milder cases this is by no means uncommon, and it now and then 
happens in the most severe. I was one of many physicians who 
were consulted in a case where violent pains of the head had re- 
sisted every means which could be thought of. The disease prov- 
ed fatal, and we expected to find great disorganization in the head, 
to which all the formidable symptoms had been referred. No 
trace of disease, however, could be found in it, and the organiza- 
tion of the liver seemed to be wholly destroyed. 

In the first stage, head-ach is generally a mere temporary affec- 
tion of the nervous system, and, indeed frequently supervenes on 



144 OP THE TREATMENT 

other nervous symptoms, which it relieves. It is particularly apt 
to be preceded by affections of the sight, and may often be re- 
moved by emetics and cathartics, which remove the immediate 
cause of irritation. When severe, indeed, it is frequently relieved 
by spontaneous vomiting. The head-ach of the second stage is 
often more obstinate. Emetics and cathartics, indeed, also fre- 
quently relieve it, because these not only remove the cause of 
irritation, but occasion depletion of the vessels of the head. The 
most effectual remedy, however, is blood-letting from the head. 
The head-ach of the first and second stages of Indigestion, besides 
the accompanying symptoms may generally be distinguished by the 
latter being greatly increased by stooping or when the patient holds 
his breath, and forces the blood towards the head, while this is 
rarely the case with the head-ach of the first stage, and never to 
the same degree, a circumstance very characteristic of the nature 
of these affections. 

The head-ach of the second stage sometimes becomes very for- 
midable when its inflammatory nature has not been understood, 
occasioning the most agonizing pain, and even delirium. No case 
of it has occurred to me in which bleeding from the head did not 
give immediate relief. Blistering the nape of the neck is often 
of service, but as it often fails, and the relief is never so speedy, 
and seldom so complete as from local blood-letting, the latter, un- 
less the strength is much reduced, is preferable; to say nothing of 
its effect on the habit in general, which, when the head-ach has 
frequently returned, is beneficial, for local of course is also general 
blood-letting as far as it goes; and from the nature of the circu- 
lation in the encephalon, the blood being returned from it by in- 
animate canals which can not partake of the excitement, there is 
no other inflammatory affection to which a generally increased 
action of the sanguiferous system so much disposes as to that of 
the brain. Blisters are a powerful means of preventing the return 
of the pain. 

It often happens, apparently for the reason just mentioned, that ■ 
this inflammatory state of the head requires a lower diet, and 
more frequent repetition of the blood-letting, than the other affec- 
tions we have been considering. 



OP INDIGESTION. 145 

Here, as in all cases of inflammation, however little general 
blood letting may seem to be indicated in the first instance, when 
local blood letting has been frequently repeated, without subdu- 
ing the hardness of the pulse, or preventing the recurrence of the 
symptoms, the greatest advantage often arises from letting blood 
generally. In such cases, indeed, it becomes indispensable. The 
strength may be exhausted by the constant repetition of the local 
blood-letting, without the tendency to the disease being subdued. 

From the blood being taken more slowly, local, even to the 
same extent, never produces the whole eflVct of general blood-let- 
ting. I have repeatedly seen the pulse softened, and the recur- 
rence of the disease prevented, by one general blood-letting, and 
that to no great extent, when frequently repeated local blood-let- 
tings had had little effect beyond the present relief they afforded. 

General and local blood letting relieve inflammation in differ- 
ent ways. The former, by lessening the vis a tergo, tends to 
prevent farther congestion in the inflamed part; the other by les- 
sening the quantity of blood in the part, to relieve more directly 
that which has already taken place. Now, although the quantity 
of blood in the inflamed part is repeatedly lessened, and thus the 
inflammation for the time relieved, the general inflammatory ac- 
tion continuing, the vessels again suffer distention, till this action 
is subdued by general loss of blood. 

On the other hand, I have seen many cases where repeated 
general blood-letting had failed to subdue inflammation, in which 
it has ceased on the local abstraction of blood. 

Here the generally increased force of the circulation had been 
sufficiently subdued, the vis a tergo sufficiently lessened; but the 
long debilitated vessels could not recover their usual diameter, till 
more directly relieved from the blood which had distended them 
beyond it. It is evident that it is in protracted cases that both 
these states must occur; but their existence seems sufficiently to 
evince the propriety of combining local and general blood-letting 
in all cases of active inflammation. 

If the foregoing observations be correct, little advantage is to 
be expected from general blood-letting, when there is no general 
19 






146 OF THE TREATMENT 



increaseed excitement of the circulation. This inference seems 
fully warranted by experience, for under such circumstances, the 
loss of two ounces of blood from the part affected often gives more 
relief than that of a pound from a distant part. 

Blood-letting seldom does much good in the head-ach of the 
first stage of Indigestion. If it is not relieved by clearing the 
stomach and bowels, and the use of what are called nervous 
medicines, a pretty large blister applied to the nape of the neck, 
or behind the ears, is the most effectual remedy. 

The effect of nervous medicines in relieving it, is often con- 
siderable, but very uncertain. In many cases they seem to do 
little or no good. Valerian and conium appear to be the most 
frequently successful. Opium is ill adapted to this head-ach, 
any relief obtained from it being generally more than compensated 
by its effects on the stomach and bowels. Opium in the head- 
ach of the second stage is out of the question; but I have found 
that after the hardness of the pulse is to a certain degree subdued, 
such a use of the compound powder of ipecacuanha as supports a 
general tendency to moisture on the surface, provided means are 
employed at the same time, to keep the bowels free, is very use- 
ful in preventing its return. The effects of this medicine seem 
sometimes improved by combining an antimonial with it. In 
many cases, particularly in the early period of the second stage, 
and when its characteristic symptoms are not very prominent, the 
head-ach seems to partake of the nature of both stages, and is 
best relieved by a combination of the above means. 

It sometimes happens in the second stage that the head-ach 
assumes a chronic form, continuing for weeks or even months, 
without being very severe. Both local and general blood-letting 
then very frequently fail to give permanent relief. The best 
means are those which support an habitually free action of the 
bowels and skin, and most effectually correct the disease of the 
digestive organs; and permanent drains from the neighbourhood 
of the head. 

Alarming as some of the inflammatory affections of the head 
are, its nervous affections connected with irritation of the diges- 































""* 






i. 







OF INDIGESTION. 



147 






tive organs, contrary to what we see in other parts, are often still 
more so; and when they occur in the second stage, supersede the 
inflammatory tendency. They appear to be of two kinds; the one 
arising from long-continued irritation of the nerves of so im- 
portant a part of the system as the digestive organs, directly de- 
bilitating and sometimes wholly destroying the source of nervous 
influence, the other from this irritation affecting the state of the 
vessels of the brain, and consequently the distribution of that por- 
tion of the blood which is sent to the head. 

The former of these is only a greater degree of the affection 
which is usual at all periods of Indigestion. Giddiness and tem- 
porary loss of power or vitiated feeling in various parts of the 
body, we have seen, are not uncommon symptoms even from 
the commencement. But it is in those cases where powerful 
and repeated causes of irritation on the one hand, and, on the 
other, the debility occasioned by long-continued indigestion, 
which every where affects the secreting power, and consequently 
the state of every part, have gradually enfeebled the functions on 
which the supply of nervous influence depends, that these symp- 
toms become formidable. It is not very unusual, under such 
circumstances, to see the patient, after more severe attacks than 
usual, and sometimes without this warning, suddenly fall down, 
and in a few hours, and in some cases, almost immediately, 
expire. 

In such cases the aids of medicine are vain. The powers of 
the constitution are not oppressed by disease, but worn out by its 
continuance. This is what in contradistinction to apoplexy aris- 
ing chiefly from the state of the vessels, is properly termed ner- 
vous apoplexy, the most fatal of all its forms; and it has been 
remarked that in some cases, no morbid appearance presents it- 
self on dissection. The fatal derangement is in the nervous sys- 
tem alone, whose structure is too minute for our observation. If 
the usual plan of bleeding in all cases of sudden insensibility be 
here resorted to, the disease is only the more suddenly fatal. 

The state of the brain in such cases resembles that which sur- 
geons call concussion. Its mechanism is deranged. The differ- 



• i#-i t 












i«*^r** 






. 



HSiSE: 




I4S 



OF THE TREATMENT 




ence is, that in the one this mechanism is deranged by a sudden 
and violent cause, applied while the powers of the system are entire; 
and which consequently, if the little strength which remains be 
carefully husbanded, may often repair the injury: the other is the 
effect of a succession of slight causes gradually changing the me- 
chanism of the brain, and at the same time exhausting the powers 
of every other part, so that the constitution possesses no means of 
repairing the injury 

Toe pure nervous apoplexy, however, as here describe!, is ne- 
cessarily an extremely r<:re disease; because it very seldom hap- 
pens that the causes continue long enough so to derange the finer 
mechanistf oi the brain as to produce loss of Junction, without 
influencing the state of the circulation in it in such a manner as 
to produce a fatal effect in this wnj, 

There is something at first view very inexplicable in the phe- 
nomena of apoplexy, such as it often appears in those who have 
long iaboured under the more severe torms of Indigestion. Dis- 
section has not only shown that sanguineous apopiexy, which is 
generally attended with a flushed countenance and strong beating 
of the temporal arteries, sometimes occurs, when from the pale- 
ness of the countenance and the previous symptoms, as well as 
nervous habit of the patient, we should have expected to find the 
blood in the brain rather below than aoove the due quantity; but 
that such is often the state of the circulation in this organ, when 
the countenance, on the attack of the apoplexy, becomes much 
paler than before, and the beating of the temporal arteries, hardly 
perceptible. Nay, such cases will often be reiiev d by blood-let- 
ting, although it is always prudent to employ it with the greatest 
caution; for, independently of other considerations, we have no 
certain means of distinguishing them from the 'case we have just 
been considering, in which blood-letting always hastens the fatal 
termination. If the case admits of relief from blood-letting, the 
smallest loss of blood from the head, is immediately attended with 
a diminution of the insensibility. 

When we consider the free communications which exist be- 
tween the vessels of the brain and those of the external parts of 



m 



ttil"^' 



OF INDIGESTION. 149 

the bead, and that both are supplied from tbe same trunks, great 
turgescence and Fulness of the former appear, at first view, alto- 
gether incompatible with a shrunk and comparatively empty state 
of the latter; yet no phvsician h^s practised long without having 
proofs of the existence of the state here described. I have repeat- 
edly seen, in an exhausted constitution, the face become suddenly 
pale, and all power lost, the patient falling down insensible, and 
the countenance continuing to increase in paleness till it assumed 
a cadaverous hue; and yet this patient has been immediately re- 
stored to the use of his faculties; the paleness of his countenance 
at the same time abating, by the loss of blood; and there is every 
reason to believe would have died without it. 

The brain, we have seen, is one of those parts which are most apt 
to sympathize with the digestive organs; even in slight attacks of 
Indigestion, its powers are uot unfrequenlly so enfeebled, that all 
its functions are impaired. This debility extends to. and indeed 
seems sometimes chiefly to take place in, its vessels.* We know, 
from the evidence of dissection, that in such cases they suffer 
themselves, and that often very suddenly, to be morbidly distended 
by the usual vis a tergo, and thus to receive a greater than usual 
share of the blood sent to the head. The external vessels conse- 
quently receive a smaller quantity; hence the paleness of counte- 
nance on the attack of this species of apoplexy, and the increasing 
paleness in proportion as the blood accumulates in the encephaion 
owing to the increasing debility of the vessels of the whole, or 
some particular part ol it 

When the minute vessels are distended, inflammation is the 
consequence; when the larger vessels, congestion, which in the 
head occasions apoplexy. In inflammation of the brain, the parts 
affected are found uniformly red. In apoplexy there is little of 
this uniform redness, but tbe larger vessels are preternatural!? 
distended.f 1 speak not here of the more common case of rup- 
ture of the vessels. 

* It appears, from direct experiment, that affections of the nervous sys- 
tem art capable of instantly depriving thr vess< Is of iheir power. — Inquiry 
into the laws of the vital Junctions, Expe'K 27, 28, 29. 

f See Inquiry into the faips of the vital functions. Second edit. p. 301 et 
s.eq. 



150 OP THE TREATMENT 

Thus it is that, in such cases as that before us, the inflamma- 
tory tendency in the brain is superseded. The trunks of the ves- 
sels themselves being debilitated and distended, can no longer 
supply the vis a tergo which supports the preternatural distention 
of the capillaries, which therefore retain their usual diameter, 
and consequently, as far as they are supplied with blood, their 
functions. 

The loss of blood takes off the state of extreme distention, 
which supports and increases the debility of the vessels, the im- 
mediate cause of which is often of a transitory nature, ami thus 
enables them to recover their usual diameter; in consequence of 
which the external vessels again receive their due proportion of 
blood. Thus, at the same time that the sensibility is restored, 
the countenance regains its colour. 

It is probable that this state of disease sometimes originates from 
causes acting directly on the brain itself; but in most instances 
we have reason to believe, that it originates from irritation of the 
stomach and other digestive organs. It is most apt to supervene 
in exhausted states of the constitution, or in what are called very 
nervous habits, and is evidently of a different nature from disten- 
tion of the vessels of the encephalon arising from general fulness, 
aggravated in the head by any occasional cause, a distended state 
of the stomach, for example, pressing on the descending aorta, a 
common cause of apoplexy in the piethoric. 

It is evident, that in the apoplexy we are considering, loss of 
blood from the head, and that only to such an extent as relieves 
the symptoms, is alone proper; although as I have witnessed, the 
incautious use of general blood-letting in such a case is followed 
by immediate relief; but it is also followed by a degree of debili- 
ty which further disposes to returns of the attack, as well as to 
other diseases. 

Slight irritations of the stomach often debilitate the external 
capillary vessels of the head, where they are most delicate, in 
consequence of which they for the time suffer moroid distention, 
particularly if the late reception of a meal gives more than usual 
vigour to the vis a tergo. Hence the flushing of the face of dys« 



OF INDIGESTION. 151 

peptics after dinner, especially when they have taken any thing 
which disagrees with the stomach. There can be little doubt, I 
think, that this tendency in irritation of the stomach to debilitate, 
and consequently occasion distention of, the vessels of the head, 
concurs with the pressure on the descending aorta to produce the 
apoplexy which is so apt to arise after a full meal. In the ad- 
vanced stages of Indigestion this effect is determined to the in- 
ternal, more readily than the external, vessels of the head, by the 
debility induced on the former, in consequence of their greater 
Sympathy with the long-continued irritation of the digestive organs. 

I had occasion to observe, in speaking of the relation which 
subsists between the sympathetic affections which attend Indiges- 
tion and the original disease, that the relation between the latter 
and urinary gravel, depends less on any sympathy which exists 
between the stomach and kidneys, than on the generation of acid 
in the alimentary canal in Indigestion. We find this observation 
further illustrated by the symptoms we have just been consi- 
dering. 

We have seen, that the internal organs, sympathetically affect- 
ed in this disease, are peculiarly liable to inflammatory affections 
in the second stage, producing the different trains of symptoms 
which have been laid before the reader. The kidneys, however, 
seldom show any tendency of this kind; although it is not un- 
common in Indigestion, for the acrid state of the urine, arising 
from the superabundance of acid and its other saline contents, 
occasioned by the greater generation of acid in the alimentary 
canal, and the inactivity of the skin, so to irritate the urinary pas- 
sages as to occasion frequent micturition, and a sense of burn- 
ing, and other painful sensations in these passages, even when no 
deposition of lithic acid* takes place in them. 

*As it is an acknowledged fact that the excessive use of distilled spirits, 
and other fluids containing 1 alcohol, tends to produce urinary gravel, 1 was 
induced to make some experiments for the purpose of ascertaining how far 
the addition of alcohol to the urine, after it is out of the body, tends to pro- 
mote a deposition of lithic acid from this fluid. 1 found, however, from re- 
peated trials, that it had a contrary tendency, both retarding the deposition 
of this acid and greatly lessening the quantity deposited, which, probablv 
in consequence of its being deposited more slowly, appeared in larger and 
more distinct chrystals when the alcohol was added to the urine. This com- 



1 52 OF THE TREATMENT 

Such symptoms may generally be relieved by diluting and mu- 
cilaginous fluids, but they can only be permanently removed by 
preventing the morbid generation of acid in the alimentary canal, 
and restoring due action to the skin. 

It is almost unnecessary to observe, that in all the foregoing 
cases we must keep in view the origin of the disease. The de- 
bility of the digestive organs, however relieved by the secondary 
disease, is easily renewed by any cause deranging their functions, 
and always has the worst effect, All the regulations respecting 
regimen, then, and even the occasional use of stomachic mecjj- 
cines are proper, as far as the symptoms of that disease admit of 
them.* 

I shall not prolong this part of the treatise by observations on 
the connexion of Indigestion with hydrencephalus internus, epi- 
lepsy, affections of the mind, and other diseases of the head, 
respecting which many valuable observations have been made by 
several writers; but close my observations on the second stage of 
Indigestion with some remarks on the manner in which it influ- 
ences the phenomena and treatment of the fevers of this country. 
By the second stage of Indigestion, we have seen, is meant such 
disorder of the stomach as has, by continued irritation, occasion- 
ed in the pylorus a state, if not of inflammation, inclining to it, 
accompanied with an inflammatory tendency throughout the sys- 
tem, which is apt to show itself chiefly in those parts which most 
sympathize with the stomach. 

On the concurrence of the second stage of Indigestion 
and Fever. 

The concurrence of the second stage of Indigestion and fever 
is perhaps the most common combination of disease which is pre- 

bines with other circumstances in proving-, that, contrary to the opinion of 
M. Majendie it is by the debility its incautious use induces on the diges- 
tive organs, and not by any direct influence on the urine, that alcohol dis- 
poses to urinary gravel. To what cause can we ascribe the diminished 
tendency of the urine to deposite lithic acid, when the common spirit of wine 
of the shops, or rum, the forms in which I used the alcohol, are added to it? 

* I have, during the last five or six years, recommended galvanism in cer- 
tain protracted cases of Indigestion. I shall have occasion, in the last chap- 
ter of this treatise, to point out the circumstances which led to its employ- 
ment, the mode of using it, and the effects to be expected from it. 



OP INDIGESTION. 153 

sented to us. It arises either from fever attacking those labouring 
under this stage of Indigestion, or from the latter supervening in 
the course of the fever. 

From the attention of physicians having lately been much di- 
rected to the local affections, which, although not essential to, 
often attended fever, has arisen one of the greatest improvements 
in its treatment; for these local affections being all of an inflam- 
matory nature, support and aggravate the general disease. 

I shall here beg leave to quote what is said of the nature of 
fever in the preface to the fourth edition of my Treatise on simple 
and eruptive fevers. The more I have considered the subject, and 
observed the course of febrile diseases, the more it appears to me, 
that the view there taken of it is consistent with the phenomena 
of those diseases, and leads to the proper treatment under their 
various forms. But my reason for troubling the reader with it 
here is, that it seems to explain the relation which subsists be- 
tween them and the disease which forms the subject of this treatise, 

Ci It is impossible to subject the whole system to sufficiently- 
minute observation, to make the immediate cause of fever the 
subject of experiment; but we know that there are local diseases 
capable of exciting fever, and it may be possible to ascertain by 
experiment the state of the part on which these local diseases de- 
pend, and thus to arrive at a knowledge of one or more changes 
in the vital organs capable of producing fever, and by comparing 
the phenomena of these diseases with those of simple fever, to as- 
certain how far the same changes which we observe in the part 
obtain throughout the system, as soon as the irritation occasioned 
by the state of that part, or any other cause, produces fever. 

"It appears, from some experiments made with the assistance 

of the microscope, related in the introduction to my treatise on 

symptomatic fevers, to which I have already had occasion to allude, 

that inflammation arises from debility of the capillary vessels, and 

their consequent distention by the vis a tergo, and that we can 

at will produce inflammation by debilitating the capillaries, and 

relieve it by increasing their action. Wherever, therefore, the 

symptoms of inflammation, increased temperature, redness and 
20 



154 OF THE TREATMENT 

swelling appeared, the capillary vessels are debilitated, and pre- 
ternaturally distended. 

" Now, in the hot stage of fever, all the surfaces are affected 
with increased temperature, redness, and swelling; and as the 
debility and consequent distention of the capillaries of a part, as 
appears from direct observation, produce increased action of the 
larger arteries of the part, this general debility and distention of 
the capillaries produce increased action of the whole arterial sys- 
tem. In inflammation, the debilitated vessels being comparatively 
few, the vis a tergo quickly, and to a great degree, distends them. 
In fever, the debilitated vessels being very numerous, it produces 
its effect more slowly, and to a less degree, in proportion as the 
resistance is greater. 

" If in any part the vessels are weaker than in others, tbey suf- 
fer a greater degree of morbid distention, particularly after the 
increased action of the heart and large vessels has been excited. 
Hence arise the congestions and inflammations so frequent in 
fever. These act as, we have seen, inflammation does in other 
cases, in supporting the morbid excitement of the heart and larger 
arteries. Thus, it is that the treatment of such affections is of 
the first importance in determining the course of the fever." 

It is unnecessary here to pursue this subject farther. The 
cause of the cold preceding the hot, stage of fever; and the modus 
operandi of the causes of this disease are considered in the above 
Treatise. 

Now, in those who labour under the second stage of Indiges- 
tion, we have seen that some of those parts which greatly sympa- 
thize with the stomach, generally suffer most. These, therefore, 
are the weak parts which most feel the effect of the morbidly in- 
creased force of circulation in fever. Their vessels are most apt 
to suffer distention, producing congestion or inflammation, accord- 
ing as the distention is in the larger or smaller vessels. 

The liver, it appears, from what has been said, is the part 
which most frequently suffers by sympathy in the second stage of 
Indigestion. It therefore often happens that, when those labour- 
ing under this stage are attacked with fever, a train of symptoms 



OF INDIGESTION. 155 

similiar to that detailed in page 138, supervenes, the proper treat- 
ment of which is essential to that of the fever. 

The principle of the treatment of these symptoms, when they 
occur in fever, is precisely the same as where they supervene 
without it, but the actual practice is not altogether so. The fe- 
ver, in its early stages, by adding to the severity of the inflam- 
matory symptoms, renders more active means necessary. Hence, 
if the general symptoms do not indicate general loss of blood, a 
greater local abstraction of it is usually proper, than when no fe- 
ver but that occasioned by the local affection attends. 

The same observation applies to the use of cathartics. At the 
commencement of fever, the free action of the bowels is particu- 
larly beneficial, and by such a state of the liver is rendered dou- 
bly so. It is thus that brisk doses of calomel at this period are 
generally more beneficial than other mercurials. 

In the latter stages of fever, on the contrary, if this affection of 
the liver still continue, which is not uncommon, either from its 
having been neglected in the early stage, or from its proving more 
obstinate than usual, I have always found the minute doses of 
blue pill above specified, given every six or eight hours, most be- 
neficial. Combined, indeed, with moderate evacuations of blood 
from the part, or (when the tenderness is inconsiderable, and the 
affection of the liver rather betrays itself by a vitiated secretion 
of bile, than by inflammatory symptoms,) blisters applied to the 
region of this organ, they rarely fail to restore due action to it, un- 
less the nature of the fever, or constitution of the patient, be very 
unfavourable; and thus often remove the fever, which, when its 
symptoms have become mild is frequently at this period prolong- 
ed by the local affection alone. 

When the sympathetic disease, previous to the attack of fever, 
has chiefly affected other parts, the bowels, the lungs, the brain, 
&c, we still find the part most affected by that disease, suffering 
most in the fever; and the same plan of treatment, mutatis mutan- 
dis, is applicable, except that the same benefit is not to be expect- 
ed from the specific operation of mercury. 

When Indigestion has not arrived at its second stage at the 



156 OF THE TREATMENT 

time the fever makes its attack, the accession of this disease, by 
increasing the inflammatory tendency, often induces that st <ge. 
The vessels, although they had not been sufficiently weakened to 
yield to the usual force of the circulation, yield to its increased 
force; and it particularly deserves attention, that an attack of fe- 
ver, as I have repeatedly witnessed, is often the means of perma- 
nently converting the first into the second stage of Indigestion; so 
that the fever leaves behind it tenderness of the epigastrium, and 
more or less hardness of the pulse, where they had not previously 
existed. 

When this is the case to any considerable degree, the patient 
generally becomes liable to a renewal of fever from slight causes; 
and if the morbid state of the digestive organs is not removed, he 
is often exhausted by repeated attacks of fever, which, as the de- 
bility increases, assume a more chronic form, and often at length 
terminate in typhus, or the more severe species of what has been 
called nervous fever. 

Local congestion or inflammation, as might be expected, al- 
though none of the symptoms of Indigestion have preceded, some- 
times takes place in fever, that is, when the force of the circula- 
tion is morbidly increased. This is most apt to happen in the 
brain or liver. 

The principle treatment, as far as I have been able ^observe, 
is still the same. In the latter case, however, the means of relief 
are generally sooner successful, and the patient bears them bet- 
ter. The treatment of fever, in those who have long laboured 
under the symptoms of Indigestion, requires great circumspection. 
It is surprising after how moderate a degree of fever symptoms of 
danger often arise in them, and indeed death itself actually en- 
sues. Both the vascular and nervous systems of some organ ne- 
cessary to life have been previously enfeebled, and it wholly loses 
its power before the fever produces any very great general effect. 
The patient dies as much of the disease under which he has so 
long laboured, as of the fever which has supervened on it, and 
that at a time perhaps when his physician's mind is fatally ab- 
stracted from the tbrmer. These observations have been so often 



OP INDIGESTION. 157 

impressed on me in the course of practice, that I can not help, in 
a particular manner calling the attention of others to them. The 
more we see of disease, we shall, I think, be the more ready to 
admit that the digestive organs form so important a part of the 
animal system, and are so intimately connected with every other 
part of it, that there is no case in which their state can with 
safety be disregarded. 

Recapitulation. 

We have now traced Indigestion from its commencement to 
the moment at which it is about to terminate in organic disease; 
for a repetition of the local affections we have been considering 
almost always terminates in change of structure which when thus 
produced, seems in no degree to differ from organic disease of 
the same parts, arising from other causes. 

It may be useful here to present to the reader a short recapi- 
tulation of the different parts of the subject which have engaged 
our attention. 

In the commencement of the disease, we have seen, that the 
muscular and nervous powers of the stomach are enfeebled, and 
that the debility gradually extends to the other parts of the ali- 
mentary canal, to the liver, and at length, more or less, to every 
part of the system. 

The irritation caused by the contents of the stomach, which, 
from the debilitated state of the nervous and muscular powers of 
this organ, have acquired morbid properties, at length produces a 
degree of inflammatory action, that is, debility of the capillary 
vessels, and its immediate consequences, in the part of the sto- 
mach most exposed to it, the symptoms of which I have regarded 
as characterizing the second stage of the disease; and, as in the 
first stage, the deranged function of the stomach produces a ten- 
dency to deranged function in every other part, in the second 
stage, every other part, in like manner, partakes of this inflam- 
matory tendency. The pulse becomes hard, and inflammation is 
every where readily excited, particularly in the parts which most 
sympathize with the stomach, or are from other causes most liable 
to disease. 



153 OF 'the treatment 

In the first stage, the debility of the nervous and muscular 
powers of the stomach is to be counteracted by attention to diet 
and exercise, and a proper use of aperient, stimulant, and tonic 
medicines; and, in proportion as it is relieved, the sympathetic 
affections, which depend on it, disappear. 

In the second stage, it is necessary to obviate the inflammatory 
tendency, and only to employ the means suited to the first stage, 
as far as they are compatible with this object; while our atten- 
tion must now at the same time be directed to the parts sympa- 
thetically affected, in which, from the longer continuance of de- 
ranged function, and the inflammatory tendency prevailing through- 
out the system, the sympathetic begins to be changed into real 
disease. 

The affection of these parts, we have seen, like that of the sto- 
mach, from which it arises, now consists in a debility of the vas- 
cular, as well as nervous, power. On these powers depend the 
secreting and absorbing processes, which are as necessary to the 
continuance of the healthy structure as the healthy function of 
the part; except that, from the nature of the function it is imme- 
diately affected, from that of the structure, its changes take place 
more slowly. 

When Indigestion has produced change of structure, it consti- 
tutes, we have seen, what I have called the third stage of this 
disease, which we are now to consider more particularly. 



OF INDIGESTION. 159 



CHAPTER IV 



OF THE THIRD STAGE OF INDIGESTION. 

The stomach is less liable to change of structure than most 
other organs. This change, therefore, although sometimes taking 
place in it, is much more frequent, as I have already had occa- 
sion to observe, in the parts with which it sympathizes. 

The diseases, which thus arise from neglected Indigestion, 
are so various, and so different from the disense from which they 
spring, as well as from each other, that to give any thing like a 
satisfactory account of them would require a treatise of greater 
extent than the whole of that now presented to the public, and a 
superficial account would be worse than none. I shall therefore 
consider only those cases, to which, from their great frequency in 
this country, my attention has been particularly directed, I mean 
the pulmonary affections produced by a disordered state, of the 
digestive organs; and the principles, which I shall have occasion 
to illustrate in treating of those diseases, will be found applicable 
to others arising from the same source. 

Organic disease, in the common acceptation of the term, is 
disease attended with such change of structure, as is apparent on 
dissection after death. This involves a change of structure in 
all the parts of the diseased organ. We can not doubt, however, 
that there is a change of structure in the finer parts of our me- 
chanism, which leaves no traces to be detected after death. Thus 
we have seen, that in those who have long been exposed to causes 
of great nervous irritation, the function of the brain and spinal 
marrow sometimes fails. The usual stimulants cease to produce 
their accustomed effects. This at first is only occasional, and 
the organs soon resume their usual functions; pointing out that, 
however their action has been oppressed, their mechanism is still 



160 OF THE THIRD STAGE 

entire; and has, if disordered at all, only been temporarily so: but, 
by degrees, the diseased state becomes more permanent; and, at 
length, sometimes ends in that species of palsy, or apoplexy, in 
which, although the permanent inability proves, dissection can not 
always detect, change of structure. 

I have often had occasion to call the reader's attention to a fact, 
which is at once evident to all in the least degree acquainted with 
the structure and functions of the animal body, that it must, ex- 
cept under partirular circumstances, be through the nervous 
system, that any organ can be influenced by a distant part. We 
have also seen an intimate connexion between the function of the 
nerves and that of the vessels in those processes, on which the con- 
stant changes going on in the body depend. The nerves of a 
secreting organ are never disordered without influencing the 
secreted fluids; and, consequently, without tending to influence the 
vessels which supply the fluids, from which those are formed. 
Thus it is, in the common course of things, that sooner or later, 
in cases of long-continued nervous irritation, the vessels either of 
the part to which the irritating cause is applied, or some part 
which sympathizes with it, deviate from the healthy state. This 
we have seen, constitutes the difference between the first and 
second stages of Indigestion. In the former, the nerves and se- 
creted fluids alone are affected; in the latter, the vessels partake 
of the disease. 

The facts just stated, however, prove, that in some cases, where 
either the nerves are more liable to disease than usual, or the 
vessels less so, a permanent change in the former takes place be- 
fore the vessels become affected, this change either occurring in 
the nerves of particular organs, or in the general source of ner- 
vous influence; producing in the one instance permanent loss of 
power in a part, in the other, in the whole system. 

This permanent change, if the animal be capable of surviving 
it, operates as all other established disease does in tending to pre- 
vent disease of other parts; and thus the vascular system of the 
organs affected, notwithstanding the vitiated state of their secre- 
tions, often for a long time, retains its healthy functions. In such 



OF INDIGESTION. 161 

cases, however, there is necessarily a tendency to affection of the 
vessels which is indicated by a degree of sharpness of pulse, 
whieh may almost always be observed in them. 

Thus we find on inquiry, that the permanent diseases of distant 
parts produced by sympathy, with the state of the stomach in 
Indigestion, are of these two kinds, namely, th.4 in whieh the 
nerves alone, and that in which both the nerves and vessels are af- 
fected. Of these the one in which the vessels as well as the 
nerves are involved, is by far the most frequent. 

Of those two kinds, then, are the sympathetic affections of the 
lungs which we are about to consider. In the one, the disease 
has extended to all the vital powers of this organ; in the other, to 
its nerves alone. 

Some years ago I presented to the Medico Chirurgical Society, 
an account of the former of these under the name of Dyspeptic 
Phthisis, which, as I have already had occasion to observe, the 
society did me the honour to publish in the seventh volume of 
their transactions. This account I am here about to present to 
the reader, with the additional observations which I have since 
made on that disease. 

The disease produced by a permanent derangement of the ner- 
vous power alone of the lungs, for want of a more appropriate 
name, I called habitual asthma My attention was first attract- 
ed to it by finding, that the difficulty of breathing proJuced by 
Indigestion, when it had lasted for a considerable time, often did 
not yield with the other symptoms of this disease; and then gen- 
erally resisted the effects of medicine. 

This affection, in many instances, gradually increases, notwith- 
standing every effort to relieve it, till it unfits the sufferer for all 
the active duties of life. It was with peculiar satisfaction, there- 
fore, that I found galvanism an almost uniform means of relief in 
it, and not unfrequently of cure. 

This induced me, in 1816, to present some observations on 
this effect of galvanism, and my reasons for believing that habit- 
ual asthma depends wholly on an affection of the nerves of the 

lungs, to the Royal Society; which did me the honour to publish 
21 



162 OP THE THIRD STAGE 

them in the philosophical transactions of the following year. I 
shall, after considering dyspeptic phthisis, lay before the reader 
the observations there published, with such additions as have since 
occurred to me. 

SECTION I. 
Of Dyspeptic Phthisis. 

It is very common for the different species of pulmonary con- 
sumption to be regarded as the same disease, and treated in the 
same way; yet it will be evident, I think, from the following ob- 
servations, that the nature of that species which I am about to con- 
sider is peculiar; and that while under the common treatment, it 
is nearly as fatal as the other forms of the disease, under that 
which is suited to it, its progress may generally in the earlier, 
and sometimes in the more advanced stages, be arrested. 

I shall in the first place, point out the symptoms by which this 
species of pulmonary consumption is distinguished; then make 
some observations on its causes, and the appearances discovered 
by dissection after death; and, in the last place, I shall detail the 
plan ol treatment which I have found most successful in it. 

Of the Symptoms. 

I had occasion about sixteen years ago, to mention this species 
of consumption and the plan of treatment which appeared to me 
best adapted to it, in my Treatise on Febrile Diseases. Since that 
time it has particularly attracted my attention: It can not, there- 
fore, I think, fail to be of some use to those whose attention has 
also been directed to it, to see the observations I have been led to 
make in so many years experience of it; for there are few diseases 
so frequent in the part of England in which I have resided, and 
indeed, I believe in most parts of Great Britain. To those whose 
attention has not yet been particularly directed to it, any obser- 
vations on it must be useful. 



OP INDIGESTION. 163 

It is not my intention to give a detailed account of the symptoms 
of this species of phthisis. I shall only mention the symptoms 
and modifications of symptons by which it is distinguished. 

It is generally preceded, as appears from what has been said, 
by symptoms of Indigestion, and particularly by those which in- 
dicate some disorder in the secretion of bile. Contrary to what 
is usual in other species of the disease, the spirits from the begin- 
ning are generally more or less depressed, and the countenance 
is sallow. 

The cougb at first is usually dry, or the patient brings up a little 
mucus after a severe, and often long-continued, fit of coughing, 
which seems to be rather the effect of the irritation of coughing 
than anything which had previously existed in the lungs; for the 
cough in this species of consumption, particularly in its early 
stages, frequently comes in violent fits, in the intervals of which 
the patient is often but little troubled with it. These fits are par- 
ticularly apt to occur after he has eaten, especially if he has eaten 
a great deal, or any thing by which the digestion is disturbed, and 
on lying down. 

In many instances they are most apt to come on when he lies 
on the left side, sometimes when he lies on the right. I think in 
almost all cases, they are least apt to occur in the recumbent po- 
sition, when the patient lies on the back rather inclining to the 
right with the shoulders a little raised; and it generally happens 
in the more advanced stages, and often before the strength is much 
exhausted, that this is the only position in which he can lie with- 
out inconvenience. It is common in this form of phthisis, as in- 
deed in all others, for the cough to be troublesome for some time 
after awaking in the morning. As the disease proceeds, the cough 
becomes more frequent, returns less decidedly by fits, and is at- 
tended with a more copious expectoration. In all these respects 
there is of course considerable variety in different cases, but in 
almost all the general character here pointed out may be observed. 
The matter expectorated is at first limpid and glairy; by de- 
grees we see intermixed with it small portions of an opake pus- 
like substance, the proportion of which in the progress of the 



164 OP THE THIRD STAGE 

disease increases; and in some cases the quantity expectorated is 
astonishing, often much greater in proportion to the severity of 
the other symptoms, than in other species of phthisis. I have seen 
half a pint or more of pus-like matter mixed with tough phlegm 
expectorated daily, when the other symptoms were comparative- 
ly mild. 

In other species of phthisis, very copious and long continued 
expectoration of pus-like matter is less common. In them such 
copious expectoration generally arises from the bursting of an 
abscess. The matter it contained, if not sufficient to occasion 
suffocation, being brought up, the quantity expectorated is again 
reduced till another abscess bursts. 

Bloody expectoration is by no means uncommon in this species 
of phthisis. Blood often appears early in the disease mixed with 
the colourless phlegm. After the pus-like expectoration com- 
mences, if blood has not previously appeared, it is much less apt 
to appear than in other forms of the disease. If it appear even 
in small quantity after this stage commences, the case generally 
proves fatal. 

While the blood is mixed only with a transparent fluid, there 
may be good hopes of recovery, certainly better than under the 
same circumstances in any other species of phthisis. A similar 
observation applies to the pus-like expectoration. If there be no 
admixture of blood, there may be good hopes of recovery, if the 
disease has not lasted long; and certainly much better than under 
the same circumstances in other species of the disease. 

The expectorated matter is less apt than in these, to assume a 
sanious appearance, but when this occurs, it seems to indicate 
nearly as much danger as in them. If it happen under the pro- 
per treatment, there is no hope. Nearly the same may be said 
of every admixture of pus-like matter and blood occurring under 
these circumstances. 

I here wave all discussion respecting the means of distinguish- 
ing pus and mucus. In my treatise on symptomatic fevers* I 

* Page 30, et seg., fourth edition. The criterion of pus, proposed by Or. 
Young, in his work on consumptive diseases, p. 27, if i<s certainty be admit- 
ted, appears to me the best, as it is tne most easy of application. 



OP INDIGESTION. 165 

have considered the question at length. It is necessary in prac- 
tice to have means of judging independent of nice experiments. 
Whether the matter I call pus-like, be pus or not, is not here the 
question; it is that to which the observations, which I am about 
to lay before the reader, apply. The only criteria, which I have 
found necessary in practice, are its pus- like appearance, and its 
sinking when so agitated in water as to separate it from the tough 
mucus, with which it is mixed. I am inclined to think that this 
substance is almost always real pus But if we know what states 
of disease are connected with these appearances in the expecto- 
rated matter, it is of comparatively little consequence whether 
what we see be pus or not. 

The breathing in the earlier stages of this species of phthisis, 
is sometimes more oppressed by the recumbent posture, than in 
other forms of the disease; and is more frequently attended with 
a sense of tightness across the pit of the stomach. The same 
observations which apply to the cough in the recumbent position, 
and after eating apply to the dyspnoea; but it often happens in 
the early stages, that there is little or no dyspnoea: and there is 
very rarely, except in the advanced stages, that marked dyspnoea 
on exercise which so frequenty attends even the commencement 
of other species of phthisis. 

There is often little or no pain. In many cases the patient is 
subject to a dull pain in the pit of the stomach, or pretty low 
down in the left side of the chest; more rarely the pain is in the 
same part in the right side. There is hardly ever a fixed pain 
high in the chest, except about the shoulders. There, it is not 
uncommon, and there is frequently an uneasy sensation and a 
sense of oppression under the sternum. 

The patient sometimes complains of darting pains in various 
parts of the chest, and frequently in more distant parts, particu- 
larly in the back and shoulders, and in the legs; and is often sub- 
ject to head-ach. 

The hectic fever is hardly ever completely formed at so early 
a period as in other species of phthisis, and sometimes there is a 
copious purulent expectoration with but slight fever, and that not 



166 OF THE THIRD STAGE 

at all assuming the form of hectic, the skin remaining dry in the 
morning, and there being little or no evening exacerbation: a 
state of the symptoms hardly ever observed in other forms of the 
disease. 

The emaciation is seldom so rapid as in other species of phthi- 
sis, but seems to keep pace with the state of the fever. 

Such is the manner in which the symptoms common to all forms 
of phthisis are modified in this species of it, but a diagnosis rest- 
ing merely on the modification of symptoms must always be fal- 
lacious; it is therefore fortunate, that in the present instance, there 
is superadded to the usual symptoms of phthisis, others peculiar 
to this species, by which, with very little attention, it may always 
be distinguished; symptoms indicating a deranged state of the di- 
gestive organs. 

The patient is often distressed with flatulence, acidity, and ir- 
regular bowels; the tongue is furred, the appetite, for the most 
part, contrary to what is usual in other forms of the disease, much 
impaired. The variety in this respect, however, is considerable. 
Sometimes there is a false appetite which fails after a few 
mouthfuls, and a sense of oppression after eating, as if there were 
not room for what had been taken. 

The alvine discharge is seldom well coloured, and the epigas- 
tric region, at the part above pointed out, is more or less full and 
tender on pressure. 

In many cases, particularly in those of some continuance, there 
is a greater degree of fulness and firmness in the right hypochon- 
dric region than in the left, often attended with tenderness on 
pressure. Much less frequently there is some preternatural ful- 
ness, and a degree of tenderness in the left hypochondric region 
also. In health, the feeling given to the hand in examining the 
two sides, is perfectly similar, as I have ascertained by repeated 
trials. The liver lying under the ribs, we press on nothing but 
the muscles and soft bowels on either side. 

The above symptoms vary much at different times, but the 
patient is hardly ever free from them. The connexion between 
them and the pulmonary symptoms is rendered evident by the 



OF INDIGESTION. 167 

latter increasing with the former, so that when the epigastric re- 
gion is very full and tender, and the flatulence and acidity more 
troublesome than usual, the cough and dyspnoea are so also; and 
on the former symptoms subsiding, the latter likewise abate. 
Even the rising of wind from the stomach, often for the time, 
removes the tendency to cough. 

The foregoing are the symptoms of the more early stages of 
this species of phthisis. In its advanced stages, it approaches 
more and more to other forms of the disease. All the symptoms, 
which more particularly indicate a tubercular state of the lungs, 
show themselves; the cough is more constant, and partakes more 
of the hacking kind, the breathing is more affected by exercise, 
and the hectic is more completely formed. 

According to a law of sympathy, to which I have had frequent 
occasion to refer, the fulness and tenderness of the epigastric and 
hypochondric regions, with the various other symptoms indicating 
derangement of the alimentary canal, now, that the disease is fix- 
ed in the lungs, are often lessened, and sometimes wholly disap- 
pear; which, if the pulmonary symptoms continue unabated, al- 
ways, I believe, affords a fatal prognosis. 

The patient at length sinks with precisely the same symptoms 
as in other species of phthisis. 

In addition to these, some other of the more prominent conse- 
quences of severe affection of the digestive organs sometimes show 
themselves, particularly dropsy of the belly, which I never knew 
to supervene in other species of phthisis. A degree of anasarca, 
the effect of debility, is not uncommon in the latter stages of all 
its species. 

Of the Causes. 

The species of phthisis which I am considering arises from all 
the causes of the other forms of this disease, with the exception 
of those whose operation is confined to the lungs themselves: the 
inhaling of dust, other diseases of the lungs, the bones pressing 



168 OF THE THIRD STAGE 

unequally on them, &c. To compensate for the want of the cau- 
ses immediately affecting the lungs, we have a numerous set of 
causes affecting the digestive organs. Drunkards, in particular, 
at that time of life which disposes to phthisis, frequently fall a 
sacrifice to this form of the disease. In short, we perceive equal- 
ly in its causes, as in its symptoms, its connexion with the state 
of the digestive organs; from which it may be justly termed dys- 
peptic phthisis. 

It particularly deserves attention, that in many families, this 
form of the disease alone appears. Its fatal effects may general- 
ly, I believe, be prevented by carefully avoiding the causes which 
tend to debilitate the digestive organs; and watching the approach 
of the symptoms enumerated in the first chapter. 

Of the appearances on dissection. 

The appearances of the lungs are generally much the same as 
in other cases of phthisis; but we almost always find at the same 
time, either a diseased state of the liver, or traces of disease 
having existed in it. In cases where the disease of the liver has 
been severe, and the patient has died as much of this disease, as 
that of the lungs, I have seen those parts of the lungs in the 
neighbourhood of the liver alone affected, the left side appearing 
sound or nearly so. 

In general, however, the affection of the liver seems to have 
little immediate share in the cause of death; and the patient lives, 
as in other cases of phthisis, till almost the whole lungs are ren- 
dered incapable of their functions. Here, as in many other cases, 
we often have occasion to remark to what extent change of struc- 
ture, even in the vital organs, may go without destroying life, 
when the change is very slowly effected; a circumstance which, 
perhaps, more than any other, shows the extent of the resources, 
by which we are enabled to counteract the more immediate effects 
of disease. 

It is not at all uncommon in dyspeptic phthisis to find the 
spleen as well as the liver diseased. As the coeliac artery divi- 



OF INDIGESTION, 169 

ding into three branches supplies the liver, stomach, and spleen, 
may we not suppose that the pain so frequently felt in the left 
side and in the epigastrium in this form of phthisis, arises from 
more than the due quantity of blood being thrown into the arte- 
ries of the two latter organs, in consequence of the obstructed 
state of the liver? Is it owing to their being supplied by the same 
artery, that we so frequently find a diseased state of the liver and 
spleen in the same subject, and that inflammations of these organs 
so frequently alternate with each other? 

Of tlie nature of dyspeptic phthisis. 

It is impossible to observe even in a cursory manner the 
symptoms of this disease, without remarking that the state of the 
lungs is connected with that of the digestive organs. Its causes, 
we have seen, afford the same inference; and in those who die of 
it, I have just had occasion to remark, we very frequently find a 
diseased state, or proofs of a diseased state having existed, in one 
of the organs of digestion. 

A question of the first importance in the treatment of this dis- 
ease here arises. What is the nature of the relation observed 
between the affection of the lungs and that of the digestive or- 
gans in this species of phthisis? Is the one a consequence of the 
other, or are they simultaneous affections arising from a common 
cause? They are not simultaneous affections, for the one almost 
always evidently precedes the other. 

In by far the majority of cases in which both the lungs and 
digestive organs are affected, the affection of the digestive organs 
precedes that of the lungs. In some instances we find the af- 
fection of the lungs the primary disease. But in these, the case 
does not assume the form above described, but that of simple 
phthisis; and the hepatic affection, which is always the most 
prominent feature of the derangement in the digestive organs 
when it is complicated with phthisis, does not show itself till a 
late period of the disease; and then seems only to influence the 
22 



170 OF THE THIRD STAGE 

symptoms by increasing the oppression and irritation and hasten- 
ing the fatal termination. 

We often observe the first of these forms of the disease arise 
from causes evidently acting on the digestive organs, and as far 
as we can perceive, in no degree on the lungs; and the last, from 
causes evidently acting on the lungs, and in no degree on the di- 
gestive organs, 

It seems to be a necessary inference from the preceding facts, 
that a diseased state of either set of organs -may produce that of 
the other. But the tendency of disease to spread from the diges- 
tive organs to the lungs is much greater, than that to spread from 
the latter to the former. We often see a slight degree of derange- 
ment in the digestive organs produce cough and other pulmonary 
symptoms, and derangement seldom exists in all the digestive or- 
gans without producing more or less of these symptoms; whereas 
it is only after disease has advanced very far in the lungs, that it 
is apt to spread to the digestive organs, and in the greater num- 
ber of instances it proves fatal without spreading to them. 

When to these circumstances we add, that all the peculiarities 
of those cases of phthisis, which are from the commencement 
accompanied with disease of the digestive organs, may be easily 
explained by the existence of this disease; and that, as I shall 
presently have occasion to point out more at length, every thing 
which relieves it, at the same time relieves the pulmonary symp- 
toms that attend it, the inference appears to be unavoidable, that 
in the species of phthisis, which we are considering, the pulmo- 
nary disease arises from that of the digestive organs. 

It is not to be overlooked, however, that it is in those most dis- 
posed to pulmonary disease that affections of the digestive organs 
most frequently produce it. We consequently see this species of 
phthisis most apt to occur in the same habit which disposes to 
other forms of that disease. This would be more uniformly the 
case, were it not that those who have weak lungs, often have 
strong digestive organs; an observation as old as Hippocrates. 
On the other hand, when the digestive organs are naturally weak, 
or powerful causes of disease in them have existed, particularly 



OF INDIGESTION. 171 

the free use of spirituous liquors, we often see it occurring in ha- 
bits apparently least disposed to pulmonary disease. 

It will place in a clearer light what has been said of the na- 
ture of the disease before us, and tend farther to illustrate the ob- 
servations which have been made on the first and second stages of 
Indigestion, to take a cursory view of the sympathy which exists 
between the state of the digestive organs, and the principal seat of 
derangement in some other diseases. I have already had occasion 
to refer to a work, which no physician, whatever may be the ex- 
tent of his experience and the accuracy of his observation, can 
peruse without advantage, although the modesty of its author has 
induced him to address it only to those belonging to his own 
branch of the profession; I mean the work of Mr. Abernethy, 
entitled " Surgical Observations on the Constitutional Origin and 
Treatment of Local Diseases " 

I believe that experience has led many others to similar views, 
but no other person has laid them before the puolic in the way 
in which Mr. Abernethy has done, and those physicians whose 
attention has been directed to the same object, must be happy to 
see in Mr. Abernetby's work, a confirmation of their own obser- 
vations; and such a confirmation as they were not likely to re- 
ceive from the work of a physician. The physician's attention is 
directed to internal disease; there his inquiries naturally begin. 
Mr. Abernethy's, for a similar reason, began with external dis- 
ease; and I believe every physician, circumstanced as I was, will 
feel as I felt on reading his work. I unexpectedly met him on a 
road where I did not expect to meet a surgeon, but where the as- 
sistance of a surgeon was of greater consequence than that of 
any physician could have been. From local, he was unavoida- 
bly carrying on his observations to general, diseases. The sympa- 
thies in question so connect them that it was impossible for him 
to do otherwise. From general, I was, for the same reason, car- 
rying mine on to local, diseases. In the case of dyspeptic phthisis 
which Mr. Abernethy relates, the reader will find the principle 
of the treatment which I have employed in that disease for more 
than sixteen years, as appears from what is said in the last volume 



1?2 OP THE THIRD STAGE 

of the edition of my Treatise on Febrile Diseases, published in 
1804; and the following cases, which occurred to me before I 
read his work, or was acquainted with his opinions, and which I 
shall relate as concisely as I can, will afford a confirmation of 
these opinions and of the practice founded on them in local 
diseases. 

I mention these cases, because, like Mr. Ahernethy's case of 
phthisis, they tend to confirm the accuracy both of his observa- 
tions and mine; for surely no stronger confirmation can be required 
of any opinion, than two observers wholly unconnected, setting 
out from the most opposite quarters, and meeting in the same 
point. My plans of practice are not precisely the same as Mr. 
Abernethy's, and in particular the mode of giving mercury in in- 
ternal disease, which 1 found most successful, is different from 
his, but the general principle is the snme. 

I have already had occasion to allude to the case of a gentle- 
man who laboured under severe pains of the legs, which had been 
treated unsuccessfully for two years. The digestive organs were 
deranged, and the epigastric region tender on pressure. A grain 
of blue pill combined with stomachic and opening medicines 
was given three or four times a day; and the pains, with his 
other symptoms, disappeared in a few weeks. A gentleman had 
sores continually breaking out in various parts of the body, which 
had proved obstinate, for which he had been advised to go 
through a regular course of mercury. The digestion was de- 
ranged, and the epigastrium tender. He took stomachic and 
opening medicines, with a grain of calomel every second or third 
night, and his symptoms disappeared in about a fortnight. A 
lady, after repeated attacks of illness, remained very weak; glan- 
dular swellings appeared in different parts of the body, and it was 
feared that what is called a general breaking up of the constitu- 
tion was about to take place. The appetite failed, the bowels 
were disordered, and the epigastrium was tender. She took 
sometimes a grain of blue pill two or three times a day, with 
stomachic and opening medicines, and at other times either a few 
grains of blue pill, or one grain of calomel, according to the state 



OF INDIGESTION. 173 

of the bowels, every second or third night; no application being 
made to the glandular swellings, but occasionally two or three 
leeches when they were tender on pressure. In about three 
months her complaints disappeared under this plan of treatment, 
nothing but a depression of spirits remaining, which was remov- 
ed by change of place. 

In one respect Mr. Abernethy's mode of giving mercury in the 
cases above alluded to, and that to which I have been led in in- 
ternal disease, arising from the sympathy of other parts with the 
digestive organs, agree. It is from small and undebilitating quanti- 
ties that good effects are to be expected in such cases: given other- 
wise it weakens the digestive organs, and often thus increases 
the disease. 

Mr. Abernethy mentions other internal diseases, particularly 
those of the head and heart, caused by the deranged state of the 
digestive organs. I have repeatedly seen his observations on 
those diseases confirmed; and could relate several cases, to which 
I have already had occasion to allude, in which the patient had 
for years laboured under symptoms of angina pectoris, and had 
been treated for this disease, in which the case yielded in a few 
weeks to minute doses of blue pill combined with stomachic and 
opening medicines. In such instances we must, of course, sup- 
pose, that no organic disease of the heart had yet supervened. 

His observations on the brain are well illustrated by two excel- 
lent treatises, by Dr. Cheyne,* and Dr. Yeates,f on the Hy- 
drencephalus Internus. It seems surprising that the immediate 
conuexion of this disease, with the state of the digestive organs 
should so long have escaped physicians. 

It is not meant that hydrencephalus internus, or any of the other 
diseases to which I allude, always arises from affections of these 
organs. In many instances they evidently arise from causes act- 
ing on the parts in which they have their seat; but were 1 to 

* A Second Essay on Hydrocephalus Jlcutus, or Dropsy in the brain, by 
J. Che>iit', XI. D., Dublin, 1815. 

f A statement of the Early Symptoms -which lead to the Disease termed Water in 
the Brain, &c , in a Letter to Martin Wall, Esq. M. D., &c, by G. D. Yeates, 
&c.; London, 1815, 



i 



174 OP THE THIRD STAGE 

speak from my own experience, I should say, that in at least 
five cases of six, this disease arises from the former cause; and 
that, in all cases, preserving a proper state of the digestive or- 
gans is the best means of prevention; for even where it arises 
from other causes, their tendency to produce it will be greater or 
less according to the state of these organs. 

It is well known that nervous affections will, if I may use the 
expression, mimic the svmptoms of almost every disease, but it 
does not seem to be generally admitted, although I think we have 
sufficient proof of the fact, that, if this mimic disease be kept up 
for a certain length of time, it will be converted into the real dis- 
ease, let the cause which produced it be what it may. The ob- 
servations made in the second and third chapters, seem sufficient- 
ly to illustrate this part of the subject. 

Of the Treatment of Dyspeptic Phthisis. 

In speaking of the treatment of this form of phthisis, I shall 
follow the same plan which was adopted in speaking of its symp- 
toms, confining myself to those circumstances in which it differs 
from the other species of the disease. 

As it appears, both from the symptoms and causes of dyspeptic 
phthisis, that the affection of the lungs is influenced by the state 
of the digestive organs, it is reasonable to suppose that the means 
which tend to improve their functions, will here be a useful aux- 
iliary to those usually employed in phthisis. In Indigestion we 
have seen that the function of the liver becomes disordered, and 
at length, some degree of fulness, and sometimes tenderness on 
pressure, of the right hypochondrium supervene. It is after these 
symptoms have supervened, as appears from what has been said, 
that disorder of the digestive organs is apt to affect the lungs; and 
it is in proportion as we relieve them, that we find the affections 
of the lungs relieved. 

This species of phthisis may be divided into three stages, in 
which the prognosis and mode of treatment are different. 

In the first the affection of the lungs is merely sympathetic, so 



GP INDIGESTION. 173 

that when the cause which produces it is removed, it ceases of 
course. This stage is distinguished by the short time which the 
disease has lasted, by the general mildness of the symptoms, the 
fever in particular being very slight, and by there generally being 
no expectoration but what the cough itself seems to occasion, 
consisting of a colourless phlegm, and for the most part in small 
quantity. 

Sometimes what is expectorated is in masses of a tough glairy 
appearance, and of a blackish hue, as if mixed with a small por- 
tion of carbon, which seem to have lain some time in the lungs; 
the expectoration of which relieves the cough, which, in this case, 
is seldom very troublesome. This last appearance of the expec- 
torated matter generally indicates the very mildest form of the 
disease. It is when there is no expectoration, or when it is thin, 
scanty, and difficult, that the disease is most apt to degenerate 
into the more alarming forms. 

In the second stage of dyspeptic phthisis, the continuance of 
the sympathetic affection has produced actual disease in the lungs. 

There are two ways in which this disease indicates itself, 
The most frequent is by some degree of inflammation superven- 
ing on the surface of some part of the bronchia, or air cells, in 
consequence of which the expectorated matter begins to be mixed 
with small portions of a pus-like substance, which gradually in- 
creases as the inflammation extends, till the quantity, we have 
seen, is often astonishingly great.* Sir Evcrard Home, in a 
treatise on the properties of pus, has shown how readily irritation 
of secreting surfaces produces it, independently of any breach of 
substance. Less frequently small vessels, in consequence of their 
being debilitated by sympathy with the state of the stomach, an- 
alogous to what we have seen sometimes happens in the vessels of 
the brain, now and then give way, which prevents the inflam- 
matory action, so that the expectorated matter presents no degree 
of the purulent appearance, but is occasionally mixed with blood. 



* The reader will find many good observations on the tendencies of in- 
flammation of the bronchial membrane in Dr. Hasting's late work on this 
subject. 



176 Ofr THE THIRD STAGE 

The symptoms now assume a more formidable character, the 
tendency to fever in particular is greater; but it seldom, we have 
seen, completely puts on the form of hectic. In this stage there 
is either no breach of substance in the lungs, or the little vessels 
which from time to time give way, soon heal. It seems to be at 
this period that tubercles generally form. These going on to sup- 
puration and ulceration, or the irritated surface of the bronchia 
and air-cells becoming ulcerated, the last stage commences, in 
which dysppptic phthisis is nearly as fatal, as any other iorm of 
the disease. 

This stage is indicated by the aggravation of all the symptoms; 
particularly by the fever assuming more perfectly the form of 
hectic, and the expectorated matter occasionally containing both 
a pus-like matter and blood; although it more frequently happens 
than in other forms of the disease that, where there has been no 
expectoration of blood at an early period, none appears afterwards. 
The expectorated matter in different cases, however, assumes all 
the various appearances observed in the last stage of other forms 
of phthisis. 

In the first stage the disease generally yields readily, except 
the dyspeptic symptoms are peculiarly obstinate (in which case 
some degree of them has generally been of long standing, or the 
patient has suffered from former attacks of the disease,) or there 
is such a tendency to a tubercular state of the lungs, that the 
hepatic affection which I have had occasion to observe always 
shows itself before Indigestion produces phthisis, and this state of 
the lungs occur almost at the same time. 

Such appear to me to be the chief circumstances which some- 
times render the disease fatal, even when properly treated, at this 
early period; but so generally successful is a proper treatment at 
this period, that it required many years' observation to convince 
me that it will not always succeed, and to satisfy my mind respect- 
ing the causes of its failure. The last ol the causes just mention- 
ed, I am convinced, is the most frequent of them. It is evident 
that when the tendency to tubercles of the lungs is very great, the 
case approaches to the nature of that form of phthisis which ori- 



OF INDIGESTION. 177 

ginates on the lungs themselves, whose fatal tendency no mode of 
treatment, however early adopted, will always pr vent. 

It often adds much to the unfavourable prognosis, to find that 
the patient has scrophulous enlargement of the more external 
glands, which is frequently such as can not be seen, but only felt. 
It will be generally admitted, I believe, that external glandular 
swellings and suppurations often tend to prevent internal disease. 
We see in the same family some fail a sacrifice to phthisis, while 
others, labouring under these swellings escape it. I have seen a 
person in the last stage of phthisis, saved by the glands of the 
neck suddenly swelling and suppurating. But that slight enlarge- 
ment of the external glands, which may rather be felt than seen, 
while it indicates, is not of sufficient importance to obviate, the 
tendency to internal disease. 

Provided there be no great tendency to tubercles, and the he- 
patic affection is not unusually obstinate, the first stage of d\ speptic 
phthisis generally yields to the usual means of relieving the cough 
and tendency to fever; combined with the milder parts of the 
treatment of the second stage of Indigestion, particularly such an 
attention to diet as prevents the stomach being oppressed, and 
counteracts the inflammatory tendency, keeping up rather a freer 
action of the bowels than is necessary in health, and taking care, 
by occasional doses of blue pill or calomel, according as the bowels 
are more or less easily acted on, to preserve a sufficiently copious, 
and healthy secretion of bile. 

I have generally given the mercurial, for the most part one 
grain of calomel combined with the compound extract of colocynth, 
when the bowels were languid; in other cases three or four grains 
of the blue pill, every second or third night, desiring the patient 
not to go out the next day, till it shall have passed off, and if it 
does not pass off in a couple, of hours after rising, to assist it by 
an aperient draught. This part of the plan must be pursued till 
the secretion of bile becomes healthy. It ought then to be discon- 
tinued, and resumed, if rendered necessary by the disordered state 
of this secretion recurring. 

By waiting a couple of hours in the morning previous to giving 
23 



178 OF THE THIRD STAGE 

the opening draught, too great an effect is avoided, and the effect 
of the mecurial on the liver better secured; both of which is more 
necessary here, than in the first stage of Indigestion; where we 
have seen it is often more our object to obtain a very free eva- 
cuation, and only the most transitory effect of the mercurial. 

The less stimulating stomachic medicines have generally been 
used, particularly when the appetite was much impaired. 

All of this class of medicines which possess any heating quality, 
have appeared objectionable. Even gentian, so useful in the first 
stage of Indigestion, seems often to increase the cough and the 
tenderness of the epigastrium. I have found extract of camomile 
flowers, combined with small quantities of the powder or oil of 
carroway, among the best stomachics in such cases; and, unless 
the strength be much reduced, Epsom salts have appeared to be 
the best assistant to the cathartic effects of the mercurial. 

The latter I have given, as appears from what has just been 
said, not for the purpose of moving the bowels, but improving the 
state of the bile, and therefore only in small doses. The tendency 
to phthisis is a strong additional argument for avoiding as much 
as possible every thing which tends to impair the vigour of the 
stomach and bowels. 

The second stage of dyspeptic phthisis, requires a plan of treat- 
ment essentially different from the foregoing. When the disease 
has been neglected till this stage commences, which is not unfre- 
quently the case, or we find that notwithstanding the employment of 
the above means, the sputa begin to assume a purulent appearance, 
or to be mixed with blood, the tenderness of the epigastrium con- 
tinuing, and an unhealthy seceretion of bile constantly recurring, 
we may be assured that the foregoing means will probably be 
ineffectual; and that if time be lost with them till the third stage 
supervenes, the termination will prove fatal. 

The following is the plan which, under such circumstances, I 
have for many years adopted, and the efficacy of which originally 
induced me to offer my observations on this subject to the attention 
of the public. It consists of a combination of the most decisive 
treatment of the second stage of Indigestion with that of phthisis. 



OP INDIGESTION. 179 

We are here to recollect, that while it is even of greater impor- 
tance than in simple Indigestion to save the strength, it is of still 
greater importance to expedite the cure, The most to be appre- 
hended from delay in the former case is an increase in the seve- 
rity and obstinacy of the dyspeptic symptoms; but in the latter, 
the structure of the lungs is threatened, and, if the cause of in- 
jury can not be removed, will soon be destroyed. 

One grain of the blue pill, combined with some mild stomachic, 
was given two or three times in the course of twenty-four hours, 
and continued either till the tenderness of the epigastric region 
yielded, and a proper secretion of bile was restored, or the gums 
appeared a little redder and fuller than natural. 

I have already had occasion to make some observations on the 
advantages arising from mercury given in minute doses. There 
is no case in which they are more conspicuous than in that be- 
fore us. As the tenderness of the right hypochondrium abates, 
and the state of the alvine discharge improves, in by far the majo- 
rity of cases the pulmonary symptoms gradually disappear. 

With the foregoing plan I have always combined means for 
the purpose of more directly relieving the tenderness of the hy- 
pochondrium. If it be slight, a succession of small blisters ap- 
plied over the tender part is often sufficient. If considerable, 
the blisters should be preceded by the loss of from two to four ounces 
of blood from this part, from which, if there be much hardness 
of pulse, although the tenderness be not considerable, great ad- 
vantage generally arises. When the disease is obstinate, or has 
repeatedly recurred, a permanent discharge from the tender part, 
especially that by a seton, often essentially promotes the cure. 

By these means the quantity of mercury required is much les- 
sened. If the tenderness be very great indeed, no quantity will 
succeed unless we reduce the inflammatory action. 

For the purpose of lessening the quantity of mercury, I have 
also combined with it such other means as tend to promote a re- 
gular and healthy secretion of bile. 

The external use of the mineral acids too much disposes to in- 
flammation to be employed in the case before us. Saline aperi- 



180 OP THE THIRD STAGE 

ents, more or less, promote a due action of the liver, and are, 
therefore, preferable to other cathartics, provided they are equal- 
ly suitable in other respects; but of the means which I have em- 
ployed with this view in dyspeptic phthisis, none has appeared 
equal to the dandelion. It ought always, perhaps, to be given in 
some form or other in this disease, if the stomach can bear it in 
large doses. 

When the patient can take a decoction of it poured upon camo- 
mile flowers for his common drink; or, what 1 have found better, 
can gradually increase the dose of the fresh expressed juice to 
two or three table spoonfuls, taken in camomile tea, three times 
a day, its beneficial effects are frequently very striking. If it 
tends to oppress the stomach, advantage often arises from infusing 
a few cloves with the camomile flowers. When the dandelion 
could be given in either of these ways, 1 have often given only 
half a grain of the blue pill twice or three times a day, and I 
think have generally found as much advantage from this dose, as 
from a whole grain without the dandelion. 

I have also, particularly where the pulse was very hard, seen 
great advantage from giving with the mercurial very small doses, 
four or five minums, of the tincture of colchicum repeated three 
or four times a day: and it is of great use in all cases to allay the 
feverish heat by nitrate of potash or saline draughts. 

If neither the tenderness of the epigastrium be removed; nor 
the gums a little affected by the above plan in about a fortnight, 
I have gradually increased the quantity of the blue pill till one of 
these effects took place. If either take place without relieving 
the pulmonary symptoms, the prognosis is bad. If the tenderness 
of the epigastrium continue, the hepatic affection is unusually ob- 
stinate: if this be wholly removed without materially relieving 
the pulmonary symptoms, we have reason to believe that the dis- 
ease has made great progress in the lungs. 

It is surprising from what states the lungs will sometimes re- 
cover, when relieved from the irritation of the hepatic affection. 
I have seen many recover not only whose friends, but whose phy- 
sicians, had lost hope of them. But in these cases the proper 



OP INDIGESTION. 181 

means had not been tried; if these have failed, the hope is no bet- 
ter than in other species of phthisis. 

Where the failure of relief proceeds from the obstinacy of the 
hepatic affection, some hope arises from a fuller mercurial course, 
but it is often fallacious; for, although such a plan as I have re- 
commended may be pursued without any diminution of strength, 
and is generally, by relieving the disease, attended with an im- 
provement of it; a freer use of this medicine, if its advantage be 
not immediately apparent, will generally be found hurtful. 

It sometimes happens that the tenderness of the epigastrium is 
wholly, but the pulmonary symptoms only partially, relieved by 
the above plan. In this case the hepatic affection is apt to recur, 
always bringing with it an increase of the pulmonary symptoms, 
till the structure of the lungs is at length destroyed. Here, if the 
recurrence of the hepatic affection be neglected, the fatal termi- 
nation is rapid. If it be carefully watched and relieved as soon 
as it appears, the case is protracted, and the decline of the patient 
gradual. I have known cases, where the progress of the disease 
had by such means been so retarded, that there was little increase 
in it in the space of several months, prove rapidly fatal on the 
adoption of another plan. 

But the most fatal case is when the hepatic affection finally 
disappears, the seat of the disease being wholly transferred to the 
lungs, as happens frequently in the last stage of this species of 
phthisis. In this case there is no hope; while the hepatic affec- 
tion continues to recur, there is always some hope, however small, 
that on its final removal, the lungs may recover. 

With respect to the parts of the treatment which are common 
to dyspeptic and other forms of phthisis, I have little to offer in 
speaking of the former. The various means found useful in other 
cases of this disease are applicable here, as far as they do not 
tend to renew or increase the affection of the digestive organs. 
I think I have found a combination of the extracts of white poppy 
and conium, the best anodyne in this form of phthisis. Opium 
is more inclined to constipate the bowels and retard the due flow 
of bile, and the anodyne power of the hyoscyamus in such doses 



182 OF THE THIRD STAGE 

as are safe, is not to be depended on. When the epigastrium is 
very tender, animal food and fermented liquors are peculiarly in- 
jurious. 

Some suppose that mercury is often useful in phthisis originat- 
ing in the lungs. I have never found it so, but I think when it 
has been employed in such cases on account of other diseases 
being complicated with them, it has almost always proved hurt- 
ful. I have remarked that in this form of the disease it never 
seems to improve the strength, as it generally does in dyspeptic 
phthisis, by improving the digestion. In them the digestion is 
generally good, and we have nothing to compensate for the de- 
bilitating effects of the mercury. 

If there be any case of idiopathic phthisis in which mercury is 
proper, it is one which I have already had occasion to mention, 
in which the pulmonary disease produces disease of the digestive 
organs; of which we still find hepatic affection the prominent fea- 
ture, and which always tends to aggravate the original disease. 
I have not, however, found it useful in such cases, which I think 
may be easily explained. In them the pulmonary affection is far 
advanced before the affection of the digestive organs appears, and 
both on this account and because the former is the original dis- 
ease, it can not be removed by removing the latter. Besides, it 
is not likely that small doses of mercury will remove the hepatic 
disease, while the cause which produced it still continues to ope- 
rate; and large doses, if they are capable of removing it, are here 
out of the question. 

l[ what has been said in the foregoing observations on dyspep- 
tic phthisis be correct, the principle of treatment in other organic 
diseases which have a similar origin may easily be inferred. 

We must combine the treatment of Indigestion with that ne- 
cessary in the disease which has supervened on it, in such a way 
as never to lose sight of the former; for, however much the af- 
fection of the digestive organs may be relieved by the establish- 
ment of another disease, it is always apt to recur; and as far as I 
have observed, the recurrence of the primary, rarely tends to 
relieve, and generally aggravates the symptomatic, disease. 



OF INDIGESTION. 183 

SECTION II. 
Of Habitual Asthma. 

I have already had occasion to make some observations on this 
disease, and to mention generally the means of relief which I 
have found most effectual. 

We have seen that Indigestion sometimes so affects the nervous 
system, or some particular part of it, that permanent debility, 
either general or partial, and that with little or no affection of the 
sanguiferous system, ensues. 

This is particularly apt to happen in the lungs when Indigestion 
has been long attended with a considerable degree of dyspnoea. 
In such cases, I have already had occasion to observe, the dysp- 
noea with a tendency to cough sometimes remains after all the 
other symptoms have disappeared, and is often but little influ- 
enced by medicine. 

It appears from experiments related in an Inquiry into the Laws 
of the Vital functions, to which I have frequently had occasion to 
refer, that after the nervous influence of the lungs and stomach 
has been greatly impaired by dividing the eighth pair of nerves, 
and folding back one of their divided ends, in consequence of 
which digestion is suspended, and the breathing rendered diffi- 
cult, the animal can be made to breathe with freedom and digest 
his food by sending the galvanic influence through the lungs and 
stomach.* 



* See an account of a repetition of the above experiments, with a con- 
firmation of their results, in the Medical and Physical Journal for May, 1820, 
by Clarke Abel, M. D., F. R. S., &c. 

Since the publication of the first edition of this Treatise these experi- 
ments have again been repeated, in consequence of several gentlemen 
still thinking that their results required further confirmation. The following 
is the very candid account given by one of these gentlemen, Mr. Brough- 
ton, in the twenty-second number of the Journal of the Royal Institution, pp. 
326, 7. - ' ' - 

Having stated that the eighth pair of nerves had been divided in the neck 
of three rabbits, pains having been taken to keep their divided extremities 
asunder, and one of the rabbits subjected to the influence of the voltaic 
battery in the way above pointed out, he observes: 

M The galvanised rabbit had remained singularly quiet the whole time^ 



184 OF THE THIRD STAGE 

It is an inference from my own experiments and observations,* 
as well as those of others, particularly of M. le Gallois, that 
what is called the nervous system, comprehends two distinct sys- 
tems, the sensorial, and the nervous system properly so called. 
Now, we have no reason to believe that galvanism can perform 
any of the functions of the sensorial system; yet, in the greater 
number of instances in which it has been used in medicine, it 
has been expected to restore the sensorial power. It has been 
expected to restore hearing, and sight, and voluntary power. It 
may now and then happen in favourable cases, from the con- 
nexion which subsists between the sensorial and nervous systems, 
that by rousing the energy of the latter, we may excite the former; 
or the sensorial power may be entire, and the fault in the nerves 
which convey its influence. From our experience of such cases, 
however, there seems little reason to hope that galvanism will 
often be successful in them. We have reason to believe, from 

breathing freely, and with no more apparent distress than the twitches 
usually produced by the galvanic influence, which in this case was uninter- 
ruptedly kept up. The other rabbits laboured strongly in their breathing. 
They were all three killed at the sume period, and their stomachs succes- 
sively opened. In the two non-galvanised rabbits, digestion had scarcely 
made any progress, but in that galvanised, it was perfect, in the manner, to 
all appearance, avowed by Dr. Wilson Philip and his supporters. However 
we may differ in opinion, as to the real state of the food in the non-gal- 
vanised rabbits, as to Dr. Wilson Philip's theory, or, as to the cause of the 
formation of chyme and chyle being found under the influence of a galvanic 
battery, Dr. Wilson Philip can not be denied the merit of correctness in 
his assertions (hitherto almost universally distrusted,) relative to the simple 
fact, of a certain power of galvanism producing digestion, after dividing the 
eighth pair of nerves, under circumstances in which it is impeded without 
the galvanism. 

" It is proper to state that the President and several members of the 
Royal Society, and of the colleges of physicians and surgeons, among whom 
were Mr. Brodie and myself, inspected the progress of these experiments, 
which were carried on under the constant superintendance of Dr. Wdson 
Philip." 

Mr. Broughton also admits that the experiments afforded reason to be- 
lieve that the nervous influence passed by nerves after they had been 
divided; and it has from experiments since made been admitted by Mr. 
Brodie and Mr. Cutler, the gentleman who was so good as to assist me in 
these experiments, that this may happen although the divided ends be sepa- 
rated by the distance of a quarter oi* an inch, provided the nerves be not 
otherwise displaced. — See a paper relating to this subject in the twenty- 
third number of the Journal of the Royal Institution. 

* See Experimental Inquiry, chap. X., and the experiments there refer- 
red to. 



OF INDIGESTION. 185 

the experiments related in the Inquiry just referred to, that gal- 
vanism has no other power over the muscular system than that of 
a stimulus;* we are, therefore, to expect little more advantage 
from it in diseases depending chiefly on faults of the sanguiferous 
system, than from other stimuli, &c. But I can not help regard- 
ing it as almost ascertained, that in those diseases in which the 
original cause of derangement is in the nervous system proper- 
ly so called, where the sensorial functions are entire, and the ves- 
sels healthy, and the power of secretion, which seems immediately 
to depend on the nervous system, is alone in fault, galvanism 
will often prove a valuable means of relief. 

As soon as the foregoing view of the subject presented itself, I 
was led to inquire what diseases depend on a failure of nervous 
influence. The effect on the stomach and lungs, of dividing the 
eighth pair of nerves,f answered the question respecting two of 
the most important diseases of this class. We have seen, that 
withdrawing a considerable part of the nervous influence from 
the stomach and lungs suspends the digestive powers, and pro- 
duces great difficulty of breathing. The following observations 
relate chiefly to affections of the lungs. Of the effects of gal- 
vanism in disordered digestion, the principal experience which I 
have had, has been in cases where it was complicated with asth- 
matic breathing. 

When the effect of depriving the lungs of a considerable part 
of their nervous influence is carefully attended to, it will be 
found, I think, in all respects, similar to the dyspnoea which of- 
ten attends Indigestion, and which, when it remains after the 
other symptoms have disappeared, I have called habitual asthma. 

In this disease the breathing is constantly oppressed, better 
and worse at different times, but never free, and often, we have 
seen, continues to get worse in defiance of every means we can 
employ. 

* Compare the experiments related in the first and second chapters of this 
part of the Inquiry with Exp. 70, 71, 72, 73, and the observations which 
follow them- 

\Exp. Jng. Exp. 44, 45, 

24 



186 OF THE THIRD STAGE 

It appeared from repeated trials, that both the oppressed breath- 
ing, and the collection of phlegm, caused by the division of the 
eighth pair of nerves, may be prevented by sending the galvanic 
influence through the lungs.* That this may be done with safety 
in the human body we know from numberless instances, in which 
galvanism has been applied to it in every possible way. 

Such are the circumstances which led me to expect relief from 
galvanism in habitual asthma. Although its effects in this dis- 
ease have been witnessed by other medical men, 1 shall mention 
nothing in the following pages which did not come under my own 
observation. 

I have employed galvanism in many cases of habitual asthma, 
and almost uniformly with relief; and have found the affection of 
the breathing as readily relieved when it appeared as a primary 
disease, as when it succeeded to indigestion. 

The time, during which the galvanism was applied before the 
patient said that his breathing was easy, has varied from five 
minutes to a quarter of an hour. I speak of its application in 
as great a degree as the patient could bear without complaint. 
For this effect I latterly found from eight to sixteen four-inch 
plates of zinc and copper, the fluid employed being one part of 
muriatic acid, and a hundred and twenty of water, sufficient. 
Some require more than sixteen plates, and a few can not bear so 
many as eight; for the sensibility of different individuals to gal- 
vanism is very different It is curious and not easily accounted 
for, that a considerable power, that, perhaps, of twenty-five or 
thirty plates, is often necessary on first applying the galvanism, 
in order to excite any sensation; yet, after the sensation is once 
excited, the patient shall not, perhaps, particularly at first, be 
able to bear more than six or eight plates. 

The stronger the sensation excited, the more speedy in general 
is the relief. I have known the breathing instantly relieved by a 
very strong power. It has generally been made a rule to begin 
with a very weak one, and increase it gradually at the patient's 

* Exp. 70, 71, 72, 73. 



OP INDIGESTION. 187 

request, by moving one of the wires from one division of the 
trough to another, and moving it back again when he complained 
of the sensation being too strong. It is convenient for this pur- 
pose to charge with the fluid about thirty plates. 

The galvanism was applied in the following manner. Two 
thin plates of metal, about two or three inches in diameter, dip- 
ped in water, were applied, one to the nape of the neck, the 
other to the lower part of the epigastric region. The wires, from 
the different ends of the trough,* were brought into contact with 
these plates, and as observed above, as great a galvanic power 
maintained, as the patient could bear without complaint. In this 
way the galvanic influence was sent through the lungs as much 
as possible, in the direction of their nerves. It is proper, con- 
stantly to move the wires upon the metal plates, particularly the 
negative wire, otherwise the cuticle is injured in the places on 
which they rest. The relief seemed much the same, whether 
the positive wire was applied to the nape of the neck, or the pit 
of the stomach. The negative wire generally excites the strongest 
sensation- Some patients thought, that the relief was most speedy, 
when it was applied to the epigastric region. 

The galvanism was discontinued as soon as the patient said 
that his breathing was easy. In the first cases in which I used 
it, I sometimes prolonged its application for a quarter of an hour, 

* I found a trough, of the old construction, more effectual in restoring 
the due action of the lungs than the improved pile. T was at first at a loss 
to account for this circumstance: from many observations, I have now reason 
to believe, that it arises from such effects of galvanism, like its other effects 
on the animal body, being proportioned, less to the quantity of electricity 
supplied by the trough, than to the intensity of its electrical and quantity of 
its chemical power, both of which are proportioned rather to the number 
of plates, than to the extent of surface. 

I have repeatedly tried the effects of a powerful electrical machine, in 
habitual asthma. They are considerable, but inferior to those of the voltaic 
trough: which I would ascribe to the former possessing much less chemi- 
cal I'.ower, in proportion to the intensity of its electricity, than the latter. 
The most powerful electrical battery will not readily decompose water with- 
out the ingenious arrangement suggested by Dr. Wollaston, for concen- 
trating, as much as possible, its electrical power; while the power of a few 
voltaic plates is, without any precaution, sufficient for this purpose. 

I have latterly found a trough, composed of plates two inches by three, 
nearly, or altogether, as effectual as one of plates four inches square. 

There is reason to believe that plates of an inch and half or two inches 
square, would answer medical purposes nearly as well as larger ones. 



188 OP THE THIRD STAGE 

or twenty minutes, after the patient said he was perfectly reliev- 
ed, in the hope of preventing the early recurrence of the dyspnoea; 
but I did not find that it had this effect 

It is remarkable, that in several who had laboured under op- 
pressed breathing for from ten to twenty years, it gave relief 
quite as readily as in more recent cases; which proves, that this 
habitual difficulty of breathing, even in the most protracted cases, 
is not ascribable to any change having taken place in the more 
evident mechanism of the lungs. 

With regard to that form of asthma which returns in violent 
paroxysms, with intervals of perfectly free breathing, I should ex- 
pect little advantage from galvanism in it, because as I have just 
observed, I found that the peculiar difficulty of breathing, which 
occurs in this species of asthma, can not be induced in animals, by 
diminishing the nervous influence of the lungs. It is probable, 
that in the human subject the cause of this disease is spasm, from 
which, indeed, it takes its name; and we have no reason to be- 
lieve, from what we know of the nature of galvanism, that it will 
prove the means of relieving any affection of this kind. 

Galvanism is sometimes useful in protracted cases of spasmo- 
dic asthma, when the fits have become less severe and more or 
less difficulty of breathing is almost constantly present; in short, 
when the spasmodic has assumed a good deal of the form of ha- 
bitual asthma. Even in these cases, however, as far as my ex- 
perience has gone, the relief afforded by it is very imperfect, and 
of short duration. It is often such, however, as very sensibly aids 
other means. 

The spasmodic asthma is comparatively a rare disease, not one 
case of it occurring for at least fifty of habitual asthma. 

Of the first cases of habitual asthma, which I saw, many oc- 
curred in work-people of the city where I then resided, who had 
been obliged to abandon their employments in consequence of it, 
and some of them, from its long continuance, without any hope 
of returning to regular work. Most of them had tried the usual 
means in vain. By the use of galvanism they were relieved in 
different degrees, but all sufficiently to be restored to their em- 



OP INDIGESTION. 189 

ployments. I afterwards saw several of them, who although 
they had not used galvanism for many months, said they had con- 
tinued to work without inconvenience, Some, in whom the dis- 
ease had been wholly removed, remained quite free from it; some 
had had a return of it, and derived the same advantage from gal- 
vanism as at first. 

The application of galvanism was confined to asthmatic dysp- 
noea. In all inflammatory cases it would he injurious; and, in 
cases arising from dropsy, or any other mechanical impediment, 
little or nothing, it is evident, is to be expected from it. 

If the secretion of bile continue to be disordered, and there is 
tenderness on pressure in the hypochondric region, the means 
which have been pointed out in the third chapter must be em- 
ployed for the purpose of relieving these symptoms previous to 
the use of galvanism; and to these means alone the dyspnoea 
sometimes yields; but I have learned from a pretty extensive 
experience, that in a large majority of such cases it will resist them, 
yet readily admit of relief from galvanism. 

If there be little tendency to inflammation, galvanism is also a 
means of relieving the affection of the digestive organs. In all 
the cases where habitual asthma was complicated with symptoms 
of Indigestion, the latter as well as the former were relieved by 
it I have repeatedly seen from it the same effect on the biliary 
system which arises from calomel, a copious bilious discharge 
from the bowels coming <m within a few hours after its employ- 
ment. This seldom happens except where there appears to have 
been a failure in the secreting power of the liver, or a defective 
action in the gail tubes. 

I have not found that the presence even of a severe cough, 
which is common in habitual asthma, in which there is always 
more or less cough, counter-indicates the use of galvanism. 
The cough, under its use, generally becomes less frequent in pro- 
portion as the accumulation of phlegm in the lungs is prevented; 
but it seems to have no direct effect in allaying it. During the 
application of the galvanism the patient is often excited to cough 
up the phlegm, which is oppressing the lungs. It frequently, 
however, disappears without being coughed up. 



190 OF THE THIRD STAGE 

In some cases the cough continued troublesome after the dysp- 
noea had disappeared. Galvanism never appeared to increase 
it, except when the inflammatory diathesis was considerable. 
In the most chronic forms of phthisis, where the symptoms had 
lasted for several years and habitual asthma had supervened, I 
have seen the relief obtained from galvanism very great, notwith- 
standing some admixture of a pus-like substance in what was ex- 
pectorated. In these cases it relieves the breathing, leaving the 
other symptoms little changed. I need hardly add, after what 
has been said, that in ordinary cases of phthisis nothing could be 
more improper than the use of galvanism. 

The dyspnoea arising from phthisis and that from habitual 
asthma are easily distinguished. The former is less variable. 
It is generally increased by the exacerbations of the fever, and 
always by exercise. When the patient is still and cool, except 
in the last stages of phthisis, his breathing is generally pretty ea- 
sy; and is seldom much influenced by changes of the weather, ex- 
cept they increase the inflammatory tendency. The latter is 
worst at particular times of the day, and frequently becomes bet- 
ter and worse without any evident cause. At the times when it 
is better the patient can often use exercise without materially in- 
creasing it. Its exacerbations are unaccompanied by any increase 
of fever. Changes of the weather influence it much. It is par- 
ticularly apt to be increased by close and foggy weather. 

When there is a considerable tendency to inflammation in ha- 
bitual asthma, the repeated application of galvanism sometimes 
increases it so much, that the use of this influence no longer gives 
relief, till the inflammatory tendency is subdued by local blood- 
letting. It always gives relief most readily, and the relief is 
generally most permanent in those cases which are most free from 
inflammatory tendency, and least complicated with other dis- 
eases, the chief complaint being a sense of tightness across the 
region of the stomach, impeding the breathing. The patients re- 
marked that the sense of tightness gradually abated, while they 
were under the influence of the galvanism, and that as this hap- 
pened their breathing became free. The abatement of the tight- 



OF INDIGESTION. 191 

ness is often attended with a sense of warmth in the stomach, 
which seems to come in its place. This sensation is most fre- 
quently felt when the negative wire is applied near the pit of the 
stomach, but the relief does not seem less when it is not felt. 

With respect to the continuance of the relief obtained by gal- 
vanism, it is different in different cases; in the most severe cases 
it does not last so long as in those where the symptoms are slight- 
er, though of equal continuance. This observation, however, 
does not universally apply. When the patient is galvanised in 
the morning, he generally feels its good effects more or less till 
next morning. In almost all, the repetition of the galvanism 
gradually increases the degree of permanent relief, but its increase 
is much more rapid in some cases than in others. 

The permanency of its good effect in the disease before us, has 
appeared very remarkable in several cases where the symptoms, 
after having been removed by it, were renewed after intervals of 
different duration, by cold or other causes. In these cases, means 
which previous to the use of galvanism, had failed to give relief, 
were now successful without its aid; or with few applications of 
it compared with those which had been necessary in the first in- 
stance. I have not yet seen any case, in which galvanism had been 
of considerable advantage, where its good effects appeared to have 
been wholly lost. Taking cold and the excessive use of ferment 
ed liquors having been the principal causes of relapse. 

The galvanism has seldom been used more than once a day. 
In some of the more severe cases it was used morning and 
evening. About a sixth part of those who have used it appear, 
as far as I yet know, to have obtained a radical cure. It in no 
cases failed to give more or less relief, provided there was little 
inflammatory tendency. It failed to give considerable relief only 
in about one-tenth; I may add, that were it only the means of 
present relief, we have reason to believe that, being more inno- 
cent, it would be found preferable to the heating, spiritous and 
soporific medicines, which are so constantly employed in this 
disease. 

As a very small galvanic power, that of not more than from 



li)Z OF THE THIRD STAGE 

four to six three-inch double plates, often relieved the dyspnoea, 
may we not hope that a galvanic apparatus may be constructed, 
which can be worn by the patient, of sufficient power to prevent 
its recurrence in some of the cases in which the occasional use of 
the remedy does not produce a radical cure? 

I wished to try if the impression on the mind, in the employ- 
ment of galvanism, has any share in the relief obtained from it. 
I found that by scratching the skin with the sharp end of a wire, 
I could produce a sensation so similar to that excited by galvanism, 
that those who had most frequently been subjected to this influ- 
ence were deceived by it. By this method, and arranging the 
trough, pieces of metal, &c, as useful, I deceived several who 
had formerly received relief from galvanism, and also several who 
had not yet used it. All of them said that they experienced no 
relief from what was done. 

Without allowing them to rise, I substituted for this process 
the real application of galvanism, merely by immersing in the 
trough without their knowledge, one end of the wire with which 
I had scratched the nape of the neck, the wire at the pit of the 
stoniach having been all the time applied as usual by the patients 
themselves. Before the application of the galvanism had been 
continued as long as the previous process, they all said they were 
relieved. I relate the particulars of the two following experi- 
ments, because they point out two circumstances of importance, 
in the application of galvanism in asthmatic cases, and in judg- 
ing of its modus operandi. 

The first was made on an intelligent lady, of about thirty-five 
years of age, who had for many years laboured under habitual 
asthma. Her breathing was very much oppressed at the time 
that she first used galvanism. The immediate effect was, that 
she breathed with ease. She said she had not breathed so well 
for many years. Part of the relief she obtained proved perma- 
nent, and when she was galvanised once a day for about ten 
minutes, she suffered little dyspnoea at any time. After she had 
been galvanised for eight or ten days, I deceived her in the man- 
ner just mentioned. The deception was complete. She told 



OF INDIGESTION. 193 

me to increase or lessen the force of the galvanism, as she was 
accustomed to do, according to the sensation it produced. I obey- 
ed her directions by increasing or lessening the force with which 
I scratched the neck with the wire. After I had done this for 
five minutes, she said the galvanism did not relieve her as usual, 
and that she felt the state of her breathing the same as when the 
operation was begun. I then allowed the galvanism to pass 
through the chest, but only through the upper part of it, the wire 
in front being applied about the middle of the sternum. She soon 
said that she felt a little relief; but although it was continued in 
this way for ten minutes, the relief was imperfect. 1 then di- 
rected her to apply the wire in front to the usual place, so that 
the influence might pass through the whole extent of the chest; 
and, in a minute and a half, she said her breathing was easy, and 
that she now experienced the whole of the effect of the former ap- 
plications of the remedy. 

To try how far the effect of galvanism in asthma arises merely 
its stimulating the spinal marroWj in a young woman who had 
been several times galvanised in the usual way, the wires were 
applied to the nape of the neck and small of the back, and thus 
the galvanic influence was sent along the spine for nearly a quar- 
ter of an hour. She said her breathing was easier, but not so 
much so as on the former application of the galvanism; and on 
attempting to walk up stairs she began to pant, and found her 
breathing, when she had gone about halfway, as difficult as before 
the galvanism was applied. She was then galvanised in the usual 
way for five minutes: she now said her breathing was quite easy, 
and she walked up the whole of the stairs without bringing on any 
degree of panting, or feeling any dyspnoea. The above experi- 
ment was made in the presence of four medical gentlemen. This 
patient, after remaining free from her disease for about half a 
year, returned to the Infirmary, labouring under a slighter degree 
of it, and experienced immediate relief from galvanism. The 
disease seemed to have been renewed by cold, which had at the 
same time produced other complaints. This is one of the cases 

above alluded to in speaking of the permanency of the good effects 

25 



1 94 OF THE THIRD STAGE 

of galvanism. On the return of this patient to the Infirmary, two 
or three applications of galvanism, combined with means which 
had given no permanent relief to the dsypncea previous to her first 
using galvanism, now soon removed it. When she first used this 
remedy, it required its constant employment once or twice a day 
for several weeks to produce the same effect. 

Many medical gentlemen, I have already had occasion to' ob- 
serve, have frequently witnessed the relief afforded by galvanism 
in habitual asthma; and Mr. Cole, the house surgeon of the Wor- 
cester Infirmary, authorizes me to say, that no other means there 
employed have been equally efficacious in relieving this disease. 

In the foregoing account of habitual asthma, I have entered 
more fully than would otherwise have been necessary, into the 
diagnostic symptoms of this disease; because it has not, in general, 
been particularly distinguished from other species of dyspnoea; 
nor indeed considered as a distinct disease, although it often ap- 
pears as such. 

Observations similar to the foregoing respecting the use of gal- 
vanism, there is reason to believe, will be found to apply to other 
cases of Indigestion; but as I observed above, I can not speak 
"with the same certainty of its effects in these cases, having made 
but few trials of galvanism in this disease, except where it was 
complicated with habitual asthma, the removal of which, by 
enabling the patient to use exercise,* no doubt contributed to a 
more healthy action of the digestive organs, which always ensued 
when these organs had been deranged, which was generally the 
case, this disease much more rarely appearing as an idiopathic 
affection, than as the consequence of Indigestion. 

In some, galvanism, at the time of its application, occasions a 
tendency to sighing; and in some, in whom it removed the dyspnoea, 
it seemed to occasion a permanent sense of sinking referred to 
the pit of the stomach. This was easily relieved by small doses 
of carbonate oi iron and bitters, without any return of the dyspnoea. 

* The effect of' indolence, in painful diseases, is often much less injurious 
than in health. Fain, if not so great as to overpower, in some degree, 
comes in place of exercise, in preserving the general activity of the functions* 



OP INDIGESTION. 195 

It generally gave a great degree of relief to the dyspnoea, when it 
produced this effect. 

In the Inquiry into the Laws of the Vital Functions, to which I 
have frequently referred, the reader will find cases related in 
which habitual asthma was relieved by galvanism^ and some in 
which it wholly removed this disease. 



THE END, 



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